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University of Northern Colorado University of Northern Colorado
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Dissertations Student Research
8-2020
Comparing Student Nurse Experiences With Developing Comparing Student Nurse Experiences With Developing
Psychiatric Mental Health Nursing Competencies in Hospital and Psychiatric Mental Health Nursing Competencies in Hospital and
Nursing Homes: A Mixed Methods Study Nursing Homes: A Mixed Methods Study
Maria M. Tice
Follow this and additional works at: https://digscholarship.unco.edu/dissertations
UNIVERSITY OF NORTHERN COLORADO
Greeley, Colorado
The Graduate School
COMPARING STUDENT NURSE EXPERIENCES WITH DEVELOPING
PSYCHIATRIC MENTAL HEALTH NURSING COMPETENCIES
IN HOSPITAL AND NURSING HOMES:
A MIXED METHODS STUDY
A Dissertation Submitted in Partial Fulfillment
of the Requirements for the Degree of
Doctor of Philosophy
Maria M. Tice
College of Natural and Health Sciences
School of Nursing
Nursing Education
August 2020
This Dissertation by: Maria M. Tice
Entitled: Comparing Student Nurse Experiences with Developing Psychiatric Mental
Health Nursing Competencies in Hospital and Nursing Homes: A Mixed Methods Study
has been approved as meeting the requirement for the Degree of Doctor of Philosophy in
the College of Natural and Health Sciences in the School of Nursing, Nursing Education
Program.
Accepted by the Doctoral Committee
_______________________________________________________
Kathryn Records, Ph.D., RN, FAAN, Research Advisor
_______________________________________________________
Lory Clukey, Ph.D., Psy.D., CNS, RN, Committee Member
_______________________________________________________
Michael D. Aldridge, Ph.D., RN, CNE, Committee Member
_______________________________________________________
Cassendra M. Bergstrom, Ph.D., Faculty Representative
Date of Dissertation Defense _____________________________________
Accepted by the Graduate School
__________________________________________________________
Cindy Wesley, Ph.D.
Interim Associate Provost and Dean
Graduate School and International Admissions
iii
ABSTRACT
Tice, Maria M. Comparing Student Nurse Experiences with Developing Psychiatric
Mental Health Nursing Competencies in Hospital and Nursing Homes: A Mixed
Methods Study. Published Doctor of Philosophy dissertation, University of
Northern Colorado, 2020.
Nurse educators today face many barriers to attracting and retaining an adequate
workforce of nurses to serve two significantly underserved and growing populations:
elders and persons with mental illnesses. The primary purpose of this study was to
compare and contrast how baccalaureate student nurses’ level of engagement and the
perceived quality of the learning environments in inpatient mental health units and
nursing homes were related to students’ (a) perceived levels of psychiatric mental health
(PMH) nursing care competency, and (b) attitudes toward working with the elderly
and/or mentally ill.
This mixed methods case study design was guided by Bronfenbrenner and
Morris’ (2006) bioecological theory of human development. The sample included 37
junior-level nursing students and three senior-level nursing students from one
baccalaureate nursing program at a medium-sized university in the Midwest who
attended mental health clinical education at a nursing home for veterans or on inpatient
acute mental health hospital units during 2018-2020. Linear regression, repeated
measures analysis of variance (ANOVA), and independent samples t-tests were used to
analyze the quantitative data collected from 37 students. A case study approach and
thematic analyses were used to develop two in-depth cases using qualitative interview
iv
data from 11 nursing students in the sample pool. Finally, the quantitative and qualitative
data were integrated by analyzing and interpreting points where the data were in
agreement and where they diverged.
There were no statistically significant differences between the groups in
perceived attainment of PMH nursing competency. Across cases, all groups made
gains from a minimum of 13 points to a maximum of 36 points pre and post
clinical scores for PMH nursing competency over four weeks. Across cases after
attending mental health clinical, a total of 9/37 (24%) nursing students expressed
they agreed or strongly agreed they were interested in a future career in mental
health nursing and 5/37 (13.5%) agreed they were interested in a future career in
geriatric nursing. However, there was a significant statistical difference between
groups in student engagement (p = .047) and satisfaction (p = .018) with students
attending mental health clinical in a nursing home being less engaged in and
satisfied with clinical education than those attending on inpatient mental health
units. The data supported that stigma, personal characteristics of students, peer
pressure, culture, and time were factors that affected student engagement in and
satisfaction with mental health clinical education.
When researching and evaluating mental health clinical education in
hospital and nursing home settings, the process-person-context-time model
(Bronfenbrenner & Morris, 2006) provided a robust framework to systematically
study variables contributing to student satisfaction and engagement. Previous
research established stigma as a significant barrier in promoting student
engagement, attraction, and recruitment to future careers working with the
v
mentally ill and elderly. There was less research about how nurse educators could
counteract stigma through curriculum reform or how other factors such as time,
personal characteristics of students, culture, peer pressure, and previous work
experience as nursing assistants impacted engagement in and satisfaction with
mental health clinical education and interest in a future career in psychiatric or
geriatric nursing. More research is needed in these areas.
Keywords: mental health clinical education, baccalaureate nursing students,
competencies, engagement, stigma, bioecological theory of human development
vi
ACKNOWLEDGEMENTS
On May 20, 2020, I successfully defended this dissertation study. I could not
have done it without the support and guidance of my Faith, family, teachers, and friends.
I acknowledge my deep appreciation and gratitude for your meaningful contributions to
my lifelong learning!
A special shout out to my dissertation committee:
To my advisor, Dr. Kathryn Records, thank you for your constant encouragement,
brilliant editing and for introducing me to my theoretical framework.
To Dr. Lory Clukey, thank you for teaching me that the purpose of a dissertation
is to learn, not to show how much you know!
To Dr. Michael Aldridge, thank you for teaching me the meaning of leadership,
the importance of good writing, and suggesting helpful resources!
To Dr. Cassendra Bergstrom, thank you for enriching my understanding of
learner-centered teaching and your wise suggestions for my informed consent and
statistics! I was blessed to be accompanied by such influential role models and
experienced navigators on this Ph.D. journey!
I want to acknowledge my research assistant: Lauren Kizlik. Lauren did an
amazing job helping with the qualitative data collection and handling. Thank you for
your hard work, flexibility, great ideas, and insights. I am grateful for the traineeship
grant from the GHR Foundation and St. Catherine University that made it possible for
vii
Lauren to assist me in the many tasks required to complete my dissertation while teaching
full time.
To my peers at St. Catherine University College for Women, your passion for
nursing and the CSJ mission of social justice inspires me to stretch a bit higher every day.
Thank you! Finally, to Katie nursing students everywhere, thanks for your willingness to
show up, work hard, and speak with love and compassion. Without you, this study would
not have been possible!
This dissertation is dedicated to the best labors of my life: my children and
grandchildren and the loves of my life: Don and Brian. I couldn’t have done it without
you! We did it!!!
With gratitude,
Maria Tice, Ph.D., RN, PHN, CNE
May 24, 2020
Memorial Weekend
viii
TABLE OF CONTENTS
CHAPTER I. INTRODUCTION TO THE STUDY ..................................................... 1
Background ........................................................................................................ 2
Statement of the Problem ................................................................................... 7
Purpose of the Study .......................................................................................... 8
Significance of the Study ................................................................................... 8
Research Questions and Hypotheses ................................................................. 9
Overview of Methodology ............................................................................... 10
Theoretical Framework .................................................................................... 14
Definition of Terms.......................................................................................... 14
Delimitations and Limitations .......................................................................... 16
Summary .......................................................................................................... 19
CHAPTER II. REVIEW OF THE LITERATURE...................................................... 20
Theoretical Research Frameworks ................................................................... 20
Bioecological Theory of Human Development ............................................... 21
Student Engagement in Clinical Learning Environments ................................ 31
Baccalaureate Student Nurse Experience in Nursing Homes .......................... 33
Competency Development in Nursing Homes ................................................ 39
Baccalaureate Student Nurse Experience in Inpatient Mental Hospitals ......... 40
Competency Development in Inpatient Mental Health Units .......................... 44
Gaps in the Literature....................................................................................... 48
Summary .......................................................................................................... 49
CHAPTER III. METHODOLOGY ............................................................................. 50
Introduction ...................................................................................................... 50
Research Design............................................................................................... 50
Context ............................................................................................................. 51
Research Participants ....................................................................................... 55
Data Collection and Handling .......................................................................... 57
Data Collection Tools ...................................................................................... 60
Data Analysis ................................................................................................... 67
Ethical Considerations ..................................................................................... 68
Conclusion ....................................................................................................... 69
ix
CHAPTER IV. FINDINGS ......................................................................................... 70
Quantitative Results ......................................................................................... 70
Qualitative Research Question ......................................................................... 75
Case One: Common Themes in Inpatient Mental Health Setting .................... 77
Case Two: Common Themes in a Nursing Home Setting ............................... 79
Cross Case Themes .......................................................................................... 84
Mixed Methods Question ................................................................................. 91
Summary .......................................................................................................... 93
CHAPTER V. DISCUSSIONS AND CONCLUSIONS ............................................. 94
Background ...................................................................................................... 94
Purpose of the Study ........................................................................................ 95
Summary of the Results by Research Question ............................................... 96
Interpretation of the Findings........................................................................... 98
Recommendations for Educators ................................................................... 104
Suggestions for Additional Research ............................................................. 106
Limitations of the Study................................................................................. 107
Conclusion ..................................................................................................... 108
REFERENCES .......................................................................................................... 110
APPENDIX A. INSTITUTIONAL REVIEW BOARD APPROVAL ...................... 128
APPENDIX B. CONSENT FORM ........................................................................... 130
APPENDIX C. BEHAVIORAL HEALTH CARE COMPETENCY (WITH
INDIVIDUAL ITEM MEAN SCORES) ....................................................... 134
APPENDIX D. ADAPTED CLINICAL LEARNING ENVIRONMENT
INVENTORY-ACTUAL ............................................................................... 137
APPENDIX E. DEMOGRAPHIC FORM .................................................................. 140
APPENDIX F. SEMI-STRUCTURED INTERVIEW PROTOCOL ........................ 142
APPENDIX G. MODIFIED BEHAVIORAL HEALTH CARE COMPETENCY... 144
APPENDIX H. GERIATRIC AND GERO-PSYCH NURSING
CURRICULUM AND COMPETENCY RESOURCES FOR
NURSE EDUCATORS ................................................................................. 146
x
LIST OF TABLES
1. Psychiatric Mental Health Nursing Concepts .................................................. 54
2. Demographic Variables for the Quantitative Sample ...................................... 56
3. Scale Reliability and Descriptive Statistics for Study Variables ..................... 65
4. Scales to Measure Student Engagement and Clinical Learning
Environment ..................................................................................................... 67
5. Correlations Between Study Variables and Demographic Variables .............. 72
6. Within and Across Case Themes ..................................................................... 85
xi
LIST OF FIGURES
1. Bioecological theory of human development .................................................. 22
1
CHAPTER I
INTRODUCTION TO THE STUDY
A mixed methods case study approach was used to compare and contrast how two
groups of baccalaureate student nurses’ engagement with people, objects, and ideas in
clinical learning environments (CLE) shaped attainment of psychiatric mental health
(PMH) nursing competencies and workplace attitudes. The two groups of interest were
(a) students attending mental health clinical on inpatient mental health units, and (b)
students attending mental health clinical in a nursing home. Research aimed at
improving mental health clinical education for pre-licensure student nurses is needed
because clinical education is the platform in which students learn to apply theory to
practice and develop nursing competency, confidence, and skill sets that match the needs
of healthcare consumers (Chan, 2002; Institute of Medicine [IOM], 2011). Many barriers
prevent realization of the pressing need for nurse educators to attract, develop, recruit,
and retain an adequate nursing workforce to care for the chronic, physical and
psychosocial health needs of two large and growing demographics: the elderly and
persons with mental illness (American Academy of Nursing [AAN], 2015; Konnert,
Huang, & Pesut, 2019). A bioecological theoretical framework (Bronfenbrenner &
Morris, 2006) guided identification and analysis of factors preventing an adequate
nursing workforce to care for elders and person with mental illness from the perspective
of baccalaureate student nurses.
2
Background
Changes in healthcare demographics, models of care delivery, and evidence-based
practices require that nurses continually learn and update their knowledge and skill sets to
meet evolving needs of healthcare systems and consumers (IOM, 2011). A concerning
trend today is stakeholder and research reports that nurses are not well prepared to meet
the psychosocial and mental health needs of patients (Benjenk, Buchongo, Amaize,
Martinez, & Chen, 2019; McAllister, Happell, & Flynn, 2014). Student nurses and
experienced medical-surgical nurses, emergency room, and intensive care nurses also
reported feeling ill-prepared, anxious, and unsure about how to care for patients with co-
morbid mental health needs despite having completed prerequisite nursing education
programs (Rutledge et al., 2013; Zolnierek & Clingerman, 2012).
The erosion of what is known in nursing as psychiatric mental health (PMH) or
psychosocial competencies from nursing curriculum, clinical education, and National
Council Licensure Examination evaluation might have contributed to this gap (Gilje,
Klose, & Birger, 2007; Kane, 2015; McKinney, Tavakoli, & Herman, 2016). There has
been no consensus about exactly what mental health nursing knowledge and skills all
entry level and practicing nurses need to deliver safe, effective, holistic care but there is
growing acknowledgement that there is no true health without mental health (Chisholm,
as cited in Kolappa, Henderson, & Kishore, 2013). Mental illnesses contribute to human
suffering, morbidity and mortality in themselves and are also risk factors that affect the
incidence and prognosis of chronic physiological diseases such as diabetes and heart
disease (Kolappa et al., 2013). Leaders in nursing, medicine, and allied health have long
sounded and responded to the call for more holistic, integrated models of healthcare
3
education and systems to address both physical and psychosocial health needs of
individuals and populations by developing standards and competencies for PMH nursing,
gero-psychiatric nursing, integrated behavioral health and primary care, and
interprofessional care (AAN, 2015; International Society of Psychiatric Nurses [ISPN]
and the American Psychiatric Nurses’ Association [APNA]), 2008; Interprofessional
Education Collaborative, 2019; Peek & the National Integration Academy Council,
2013).
However, in most baccalaureate nursing programs in the United States today, both
classroom theory and clinical education remain “silo-ed” with students learning about
acute health conditions, mental health, and public health/community nursing in separate
courses and clinical settings. This fragmented approach has complicated students’ ability
to transfer content learned in skills labs and classrooms to the actual care of patients in a
manner that facilitates holistic assessment of physiological, psychosocial, and population-
based influences on health (McKinney et al., 2016; Newton, Billett, Jolly, & Ockerby,
2009). Additionally, a greater percentage of classroom and clinical time has been
devoted to physiological integrity than psychosocial integrity. Studies found students and
practicing nurses tended to prioritize patients’ physical needs over psychological needs
(Kane, 2015; Mersin, Demiralp, & Öksüz, 2019). For example, in one well-established,
accredited, four-year Bachelor of Science in Nursing (BSN) program in the United States,
the number of clinical practice hours allotted to mental health clinical was 35 hours (4
days/8 hours + 3 hours orientation) and for the community and public health clinical, the
number of hours was the same. The number of acute care clinical practice hours students
completed between the sophomore and senior year was approximately 275 hours. This
4
was more than 8.5 times the amount of community public health and mental health
clinical practice hours despite shifts in health care requiring that nurses be educated to
provide holistic, population-based care and case management across the continuum of
care (IOM, 2011).
The reasons for the prioritization of physiological health over psychosocial health
and population-based approaches in nursing curriculum were varied and some were
unclear. Current emphasis on evidence-based practice from the perspective of a medical
model might undermine value placed on the primacy of the therapeutic relationship—the
bedrock of PMH nursing (Kane, 2015; Peplau, 1997). Within society and healthcare
systems, mental illness is often stigmatized with less prestige, money, time, and other
resources going toward mental health services and research (Sabella & Fay-Hiller, 2013).
Shortages of nurse educators and preceptors with expertise in mental health and available
clinical sites, including mental health sites, have been significant barriers affecting
implementation of clinical education, which were well established in the current literature
(National Council of State Boards of Nursing [NCSBN], 2019). McKinney et al. (2016)
reported that simultaneous overcrowding of students from multiple nursing programs at
mental health clinical created frustration for both staff and students. leading nurse
educators to seek alternative experiences for mental health clinical education through use
of simulation and/or alternative clinical sites in the community (Choi et al., 2016;
McKinney et al., 2016).
Evidence showed that while up to 50% of nursing education could be replaced
with simulation, clinical experience with patients in authentic health care settings could
not be eliminated without negative effects on student nurse readiness for practice upon
5
graduation (NCSBN, 2019). Additionally, scant evidence supported how many hours of
classroom theory and clinical practice were needed to develop particular nursing
competencies (Bowling, Cooper, Kellish, Kubin, & Smith, 2018). In the United States,
only 10 states outlined requirements about the number of clinical practice hours nursing
programs were required to provide, resulting in a wide variation of clinical hours
provided across nursing programs (Bowling et al., 2018; IOM, 2011).
The prioritization of physiological nursing care over psychosocial nursing care
needs of health care consumers has been especially concerning because in the United
States, two patient populations are widespread and growing: (a) the elderly—defined as
persons aged 65 and older, and (b) persons of all ages with mental illnesses. The U.S.
Census Bureau (Ortman, Velkoff, & Hogan, 2014) reported that by 2050, the number of
U.S. residents age 65 and over was projected to be 83.7 million, almost double its
estimated population of 43.1 million in 2012. With larger numbers of older adults, there
will be an increased need for geriatric care including care for individuals with chronic
diseases and co-morbidities (American Association of Colleges of Nurses [AACN], 2019,
para. 5).
Likewise, the numbers of people with mental illness are prevalent in the United
States and globally. Across the lifespan, one in five people experiences a significant
mental illness within any given year (National Alliance on Mental Illness, 2019).
Depression is currently the leading cause of disability in the world (World Health
Organization, 2018). Among older adults living in the community, 40% are estimated to
have a mental health problem, depression and anxiety being the most common (Li &
Conwell, 2007; Wang, Kearney, Jia, & Shang, as cited in Konnert et al., 2019). Although
6
older Americans comprise 13% of the population, they account for 20% of people who
commit suicide (American Psychological Association [APA], 2019). In fact, older
Americans have the highest suicide rate of any age group.
Mental illnesses are especially prevalent in nursing homes. Up to two-thirds of
nursing home residents have a diagnosable mental illness such as anxiety or depression
(APA, 2019). As many as 50% of residents living in nursing homes have some form of
dementia and about 67% of people with dementia die in nursing homes (Alzheimer’s
Association, 2007). The number of people with Alzheimer’s is projected to sharply
increase from more than 5 million today to as many as 16 million by 2050 as 78 million
Baby Boomers mature and reach the age of highest risk (Alzheimer’s Association, 2020).
Health and long-term care organizations rely heavily on the services of registered
nurses to care for these populations. Given the incidence of mental and behavioral health
conditions present in nursing homes, students might be able to develop PMH
competencies in long-term care (LTC) settings, alleviating overcrowding at inpatient
mental health sites as well as providing valuable opportunities for students to gain
experience working with elders. Nursing homes, prevalent in almost every community
including rural areas, might provide accessible and appropriate CLEs for mental health
clinicals. A few studies evaluated healthcare students’ abilities to develop
interprofessional competencies, physical assessment, therapeutic communication, and
fundamental nursing skills but not comprehensive PMH competencies as the focus of the
practicum and site for the mental health clinical (Mezey, Mitty, & Burger, 2009;
Muralidharan, Mills, Evans, Fujii, & Molinari, 2019).
7
Statement of the Problem
A reality facing healthcare systems in the United States is the growing demand for
registered nurses who have skill sets to provide safe and effective nursing care to older
adults with chronic physical and mental health needs (Delaney, 2016; Husebø, Storm,
Våga, Rosenberg, & Akerjordet, 2018; Skaalvik, 2011). Workforce shortages of
qualified staff to meet the psychosocial and mental health care needs of healthcare
consumers has been especially noticeable in nursing homes where direct patient care is
most often provided by certified nursing assistants (CNAs) who might not have received
additional training in recognition and management of signs and symptoms of mental
illnesses or how to manage aggressive behaviors, paranoia, and hallucinations that often
accompany dementia or delirium (Konnert et al., 2019). Lack of education and training
in mental health management has been identified as a primary factor impacting job
satisfaction and retention of direct care workers including both paraprofessionals and
registered nurses (Konnert et al., 2019). According to Castle and Engberg (2005), one-
year turnover rates in LTC were as high as (a) 60-75% among direct care workers such as
home health aides and certified nursing assistants (CNAs), (b) 85.5% for licensed
practical nurses (LPNs), and (c) 55.4% for registered nurses (RNs) in the United States.
The demand for nurses with expertise in geriatric nursing and/or gero-psychiatric
nursing far has exceeded the supply (AAN, 2015). Ongoing workforce shortages and
stigmatized societal attitudes that devalue work with these populations perpetuate cycles
of rapid staff turnover and high vacancy rates due to stress and burnout (AACN, 2019;
Konnert et al., 2019). Stress and burnout could lead workers to become detached and
8
disengaged from patients, which significantly impacts the quality of health care and
patient outcomes (AACN, 2019).
Purpose of the Study
The primary purpose of this study was to compare and contrast how baccalaureate
student nurses’ level of engagement and the perceived quality of the learning
environments in inpatient mental health units and nursing homes were related to their (a)
perceived levels of PMH nursing care competency and (b) attitudes toward working with
the elderly and/or mentally ill.
Significance of the Study
This study addressed a gap in understanding about whether or not students could
develop knowledge and skills commonly categorized as PMH nursing competencies in
nursing homes at the same level as in inpatient acute mental health units, which are
generally thought to be the gold standard CLE for development of PMH competencies.
This gap in understanding has been further clouded by the lack of a standardized
definition and consensus within the nursing profession of what essential PMH
competencies for baccalaureate nurses are or should be, how to measure them, and how
much of the nursing curriculum and clinical experience should be allotted to developing
them. Even though professional organizations have developed guidelines and some
measurement tools exist to identify essential PMH, geriatric and geropsychiatric nursing,
and interprofessional behavioral health care competencies for entry level nurses, these
have not been widely discussed or researched, resulting in wide variation in the
classroom and clinical experiences devoted to developing geriatric and PMH
competencies in baccalaureate education (American Psychiatric Nurses Association,
9
International Society of Psychiatric Mental Health Nurses, & American Nurses
Association, 2014; Gilje et al., 2007).
Studying ways in which nursing homes might be used as PMH clinical learning
sites for baccalaureate nursing students could potentially bring mutual benefits to nursing
homes and nursing education programs, which would improve the psychosocial
competencies and confidence of both nursing home staff and student nurses. The use of
nursing homes as a site for PMH clinical education could also ease overcrowding of
students in acute inpatient mental health clinical sites. There are approximately 15,600
nursing homes in the United States with 1.7 million licensed beds occupied by 1.4 million
patients as compared to approximately 170,200 psychiatric specialty beds in state,
county, private, and public hospitals; Veterans Affairs Centers; and residential treatment
centers in the United States (Centers for Disease Control and Prevention, 2016; National
Association of State Mental Health Program Directors, 2017). If nursing homes provide
a favorable clinical learning environment in which students could learn PMH nursing
competences and gain experience working with elders, more students might be attracted
to consider future careers working with elders or in mental health, thereby building the
workforce in these critically underserved areas.
Research Questions and Hypotheses
The following research questions and hypotheses guided this study:
Q1 Is there a relationship between baccalaureate student nurses’ level of
engagement in mental health clinical education and the perceived quality
of the CLE with changes in their PMH nursing competencies?
H01 Level of student engagement in mental health clinical and the quality of
the CLE are not associated with attainment of PMH nursing competencies.
10
H1 Level of student engagement in mental health clinical and the quality of
the CLE are associated with attainment of PMH nursing competencies.
Q2 Does mental health clinical education in a nursing home or on inpatient
mental health unit have a significant effect on nursing students’ attainment
of PMH nursing competency and interest in a future career in mental
health or gerontological nursing?
H02 There are no significant differences between the two groups in PMH
nursing competency attainment or interest in a future career in mental
health or gerontological nursing.
H2 There are significant differences between the two groups in in PMH
nursing competency attainment or interest in a future career in mental
health or gerontological nursing.
Q3 What is the student nurse experience of attending PMH clinical education
in nursing homes versus inpatient mental health units?
Q4 To what extent do the similarities and differences between the groups
identified by the quantitative data support or contradict the qualitative
data?
Overview of Methodology
This mixed methods, collective case study design was guided by the process-
person-context-time (PPCT) model in Bronfenbrenner and Morris’ (2006) bioecological
theory of human development (BTHD). A collective case study design is one where
qualitative and quantitative data are collected and analyzed to generate two or more
cases. In this study, two cases were comprised of baccalaureate nursing students
attending a mental health clinical one day a week for eight hours over four weeks in two
different clinical settings during 2018-2020. One setting was on adult inpatient mental
health units in a Level I acute care hospital (Case 1) and the other setting was a long-term
care facility for veterans in an urban area (Case 2).
The purpose of the clinical experience was for students to be able to connect
concepts learned in mental health theory classes to the actual care of persons with mental
11
illnesses and move toward entry level competency in PMH nursing by graduation in May
2021. A mixed methods case study design fit the purpose of this study to compare and
contrast similarities and differences between student development of PMH nursing and
changed attitudes within and across the two cases. A case study approach allowed for an
in-depth, multi-faceted exploration of a complex phenomenon in real-life settings, which
was the context for this study (Crowe, Creswell, & Robertson, 2011). Case studies are
useful when phenomena being studied are complex and cannot be easily controlled by the
researcher (Crowe et al., 2011). Case studies can be used to build new or refine existing
theories (Crowe et al., 2011).
After Institutional Review Board (IRB) approval (see Appendix A) and student
consent (see Appendix B) were obtained, quantitative data obtained from surveys
conducted throughout Fall 2019 and Spring 2020. Students completed the following
surveys online within the course electronic platform at the start and end of each semester:
the modified Behavioral Health Care Competency (BHCC; Rutledge, Wickman, Drake,
Winokur, & Loucks, 2012; Tice, 2018) and the Adapted Clinical Learning Environment
Inventory--Actual (CLEI-A; Chan, 2002) with four researcher-developed items to
measure engagement (based on the work of Reeve & Tseng, 2011). Data for each
individual in the clinical groups were not accessed or analyzed by the researcher until
after participants had completed mental health clinical and received their clinical grade.
Appendix C provides the BHCC (Rutledge et al., 2012) and Appendix D provides the
CLEI-A (Chan, 2002).
Two standardized competency measurement tools—the BHCC tool and a tool for
public health nursing competencies—were used by faculty teaching mental health and
12
community public health nursing theory as a means of aligning clinical professional
competencies with classroom concepts. All students at the junior-level in the BSN
program in the College for Women were asked to complete the BHCC (Rutledge et al.,
2012) accessed online through the course learning platform. Students received one
course participation point in the non-exam category when they completed these surveys.
This small incentive motivated most students to complete the BHCC but completion was
voluntary. The classroom instructors did not view individual results unless the student
asked to discuss these. However, faculty viewed BHCC aggregated statistics to
determine areas of competency development in which students felt more and less
confident. This information was utilized to guide classroom teaching to address
identified areas of student learning needs.
In 2019-2020, post mental health clinical, junior-level nursing students were
asked to complete the CLEI-A (Chan, 2002) and four researcher developed Likert items
in an online survey accessed in the course electronic learning platform for purposes of
program evaluation. Collecting data to evaluate learning outcomes for students in the
two mental health clinical sites was important because a nursing home is not the standard
setting for mental health clinical education; therefore, evidence was needed to evaluate
the appropriateness of this instructional strategy. Demographic data related to student
age, first language, prior health care, or mental health work experience were collected
from students who consented to have their existing quantitative data included in the study
at the time they signed the research consent in spring semester 2020 (see Appendix E for
demographic data form).
13
Quantitative data from the modified BHCC (Rutledge et al., 2012) and CLEI-A
(Chan, 2002) were examined, cleaned, assigned a numeric code, and entered into SPSS
Version 23 (IBM Corporation, Armonk, NY). Descriptive statistics were calculated to
check for normal distribution. Cronbach’s alpha was done to check validity of the
inventories for this population. The data were analyzed with appropriate inferential
statistics for the research questions. Results of the quantitative analysis were interpreted,
summarized, and discussed.
Students who agreed to be interviewed were contacted for qualitative interviews
in Spring 2020. One-on-one interviews using a semi-structured protocol (see Appendix
F) based on the PPCT model were used (Bronfenbrenner & Morris, 2006). Students
could request a one-on-one interview with the researcher or research assistant, whichever
they chose. Prior to March 13, 2020, interviews were held with the participant and the
interviewer in a private distraction-free room in the nursing department and were audio-
recorded to aid in accurate transcription. After March 13, an IRB amendment was
obtained so all interviews could be done online using Google Hangouts (see Appendix
A). This was necessary due to the coronavirus pandemic.
Qualitative interviews proceeded until saturation was reached. Eleven interviews
were transcribed using Trint transcription software. Transcripts were edited with
personally and contextually identifiable information removed before being uploaded in
NVIVO Version 12. The research assistant de-identified the transcripts and assigned
numeric data to link qualitative, quantitative, and demographic data.
Thematic analysis was used to identify themes that aligned with the PPCT model
guiding the study (Bronfenbrenner & Morris, 2006; Creswell & Poth, 2018). To promote
14
reliability, two readers (the researcher and research assistant) separately identified and
discussed themes. The researcher created in-depth portraits both within and across cases.
Then, quantitative and qualitative data were merged by comparing and contrasting
similarities and differences. Results were related to previous study findings and then
discussed with conclusions and recommendations drawn. Member checking was used to
confirm the accuracy of the conclusions or any quotes from the participants.
Theoretical Framework
This study was concerned with examining and understanding how student
engagement in proximal processes—defined as interactions with persons, objects, and
ideas in CLEs over time—affected development of PMH nursing competencies and
attitudes. Bronfenbrenner and Morris’ (2006) PPCT model was the lens chosen to focus
the study. This theory was chosen to guide the study because it was concerned with
human development whereby the developing person is influenced by and influences the
environment (Rosa & Tudge, 2013). The PPCT model operationalizes contributors to
human development with four constructs: person, processes, context, and time
(Bronfenbrenner & Morris, 2006). The PPCT model (Bronfenbrenner & Morris, 2006) is
discussed in detail in Chapter II. In this study, proximal processes were thought to be
closely related to the concept of student engagement (Bernard, 2015).
Definition of Terms
In this section, the major concepts of engagement, clinical learning environments,
competency, and PMH competency are defined.
Behavioral health care competencies and psychiatric mental health nursing
competencies. Behavioral health care (BHC) is an umbrella type of care used for
15
any problems that impact overall health including mental illness and substance
abuse, stress-linked physical symptoms, aggression, and ineffective health
management behaviors (Peek & the National Integration Academy Council,
2013). Behavioral health care is broader than mental health care as it
encompasses understanding the bio-psycho-social variables that influence mental
health conditions, stress-related disorders, addictive disorders as well as an
understanding of theories and strategies to help people engage in successful
behavioral change such as motivational interviewing. In this study, this researcher
used the terms psychiatric mental health nursing (PMH) competencies and
behavioral health care competencies (BHCC) synonymously. Psychiatric mental
health nursing competency was chosen because this term is most often used in
nursing education today—not behavioral health care nursing. This might change
in the future as healthcare education becomes more interprofessional.
Clinical learning environment. Learning environment refers to “the social interactions,
organizational cultures and structures, and physical and virtual spaces that
surround and shape participants’ experiences, perceptions, and learning” (Josiah
Macy Foundation, 2018, p. 35). The CLE is “an interactive network of forces
within the clinical setting that influence students' learning outcomes” (Chan,
2002, p. 70). In this study, measurement of the CLE in the quantitative strand
was operationalized through use of the CLEI-A subscales of personalization
(seven items), task orientation (five items), innovation (six items), and
individualization (four items; Chan, 2002).
16
Competency. Defined as “a complex know-act that is based on combining and
mobilizing knowledge, skills, attitudes, and external resources and then applying
them appropriately to specific types of situations” (Tardif, in CASN, 2015, p. 8).
Engagement. Based on Bronfenbrenner and Morris’ (2006) PPCT model, engagement is
defined as the quantity and quality of experiential interactions by student nurses
with the persons, objects, ideas, and contextual factors in CLEs over time.
Bernard (2015) defined student engagement as
a dynamic reiterative process marked by positive behavioral, cognitive, and
affective elements exhibited in pursuits of deep learning. This process is
influenced by broader contextual preconditions of self-investment, motivation,
and a valuing of learning. Outcomes of student engagement include satisfaction,
sense of well-being, and personal development. (p. 1)
In this study, measurement of student engagement in the quantitative
strand was operationalized through use of the Adapted Clinical Learning
Environment Inventory subscales of student involvement, satisfaction, and four
researcher-created items (Chan, 2002).
Delimitations and Limitations
Delimitations
Delimitations are factors that restrict the questions one can answer or the
inferences drawn from research findings based on intentional choices made a priori about
the boundaries of the study design (“Diving deeper,” 2019). This study was limited to a
convenience sample of 88 second and third semester and 63 fourth semester pre-licensure
nursing students in one BSN program in the Midwestern United States who either were
17
currently or had previously attended mental health clinical in two different CLEs. This
study focused on PMH nursing competency development and student nurse attitudes
toward two populations: the mentally ill and elders in nursing homes. Findings might not
be generalizable to other groups of student nurses, care settings, or development of
particular nursing knowledge, skills, or attitudes (competencies) overall. The literature
review for this study was primarily limited to research studies conducted from 2009 to
2019.
Another choice that affected the study was to refer to behavioral health care
competency and mental health nursing care competency synonymously. Whether or not
the two terms were synonymous brought up linguistic and philosophical arguments
beyond the scope of this study. However, the difficulty this researcher had identifying a
standardized definition for PMH nursing care competency in the literature as well as the
lack of an existing standardized set of core PMH nursing concepts and taught in all
baccalaureate level nursing curricula in the United States suggested that lack of a core
definition and standardization impacts nursing education and warrants more research.
The setting for the nursing home research group was a Veterans long-term care
center with many resources other nursing homes might not have. Access to onsite
psychologists, a psychiatrist, behavioral health analysts, a domiciliary room and board
that served a high percentage of veterans with mental illness or substance use disorders,
and day respite program provided many rich opportunities to learn from an
interdisciplinary team. Additionally, more mental health conditions such as
posttraumatic stress disorder and traumatic brain injuries were more likely present in
18
Veterans homes due to traumatic events experienced in war. Therefore, the experiences
of students in a Veterans home might not be generalizable to other LTC settings.
Limitations
Limitations of the study included a small sample size for the quantitative strand.
The use of a convenience sample limited generalizability of the study; however, this was
offset somewhat because the students were randomly assigned to one of two clinical
settings by the course coordinator. The study was conducted within one nursing program
in a College for Women so all the participants were women, most of them were in their
early to mid-20s, and 35% were students of color. Survey tools used to measure student
mental health competency levels and student satisfaction with the CLE relied on student
self-evaluation and, therefore, could have been inaccurate or biased. The dual roles as
researcher and classroom/clinical instructor could also have affected the study as
remaining objective and bracketing interpretation of the data was challenging. The
assistance of the research assistant, who was not involved in teaching and did not know
the students, was invaluable for maintaining objectivity in the study. At the same time,
this researcher’s position as a participant observer of the students in the clinical settings
also provided opportunities to make valuable observations in a naturalistic setting, which
could not be captured by survey data alone.
Clinical learning environments are complex, dynamic psychosocial arenas (Chan,
2002). Likewise, organizations are influenced by sociocultural influences and differences
that might make it difficult to generalize findings from one type of setting in one location
to a similar type of study in another location. Chapter III further describes the research
design elements chosen to strengthen the study.
19
Summary
This chapter introduced the study including the background, purpose, statement of
the problem, significance, research questions and hypotheses, overview of the
methodology and theoretical framework, definition of terms, as well as delimitations and
limitations. Chapter II presents the theoretical framework chosen to guide the study, a
review of relevant literature, and gaps in the research literature that supported the need
for the study.
20
CHAPTER II
REVIEW OF THE LITERATURE
This chapter reviews literature related to the concepts of (a) student engagement
in clinical learning, (b) student perceptions of learning and competency development in
nursing homes, and (c) student perceptions of learning and competency development in
inpatient mental health units. Theoretical frameworks used to guide previous studies of
these concepts are discussed. Bronfenbrenner and Morris’ (2006) bioecological theory of
human development, specifically the PPCT model that guided this study, is critiqued to
provide readers with a foundational understanding of the theory’s purpose, major
constructs, and assumptions (Chinn & Kramer, 2015). The rationale for selecting the
PPCT model is explained. Finally, the results of the literature review are summarized
including gaps in research that guided considerations for research design and supported
the need for the study.
Theoretical Research Frameworks
Past research on student nurse learning in clinical education initially focused on
nursing students’ perception of the CLE in acute care hospital settings (Chan, 2003) but
that changed in the wake of the IOM’s (2011) recommendations that nursing students be
prepared to practice across settings and in the community. Currently, more studies about
the student clinical learning experience in non-traditional clinical settings including
nursing homes and inpatient and community mental health care settings are being
conducted (Bisholt, Ohlsson, Engstrom, Johansson, & Gustafsson, 2014; Bjørk, Bernsten,
21
Byrnildson, & Hestetun, 2014; Choi et al., 2016; Grav, Juul, & Hellzén, 2010; Husebø et
al., 2018; Karimollahi, 2012).
Nurse researchers have contributed substantively to building an evidence base to
better understand CLEs through concept analysis (Flott & Linden, 2016), the
development and validation of eight tools to measure CLEs (Mansutti, Saini, Grassetti, &
Palese, 2017), and empirical research. Theoretical models used in these studies were
largely borrowed from educational and psychosocial disciplines (Bloom, 1964; Dewey,
1933; Knowles,1990; Kolb, 1984; Moos, 1974). Nursing studies of the CLE influenced
by sociocultural, constructivist, and critical action frameworks viewed student learning
and competency development in CLEs as being socially constructed through interactions
and perceptions of individuals, groups, communities of practice, and cross-organizational
networks (Lave & Wenger, 1991; Vygotsky, 1978).
Theoretical frameworks to study student learning outcomes in clinical education
from the perspective of student engagement in clinical education have used a variety of
middle range theories including (a) Schaufeli and Ezzmann’s integrative model of
burnout (Bruce, Omne-Ponten, & Gustavvson, 2010), (b) Pintrich’s achievement goal
theory (Chen et al., 2016), (c) Billett’s concept of workplace participatory practices
(Liljedahl, Bjorck, Kalen, Ponzer, & Laksov, 2016), and (d) Astin’s model of
involvement (Prokess & McDaniel, 2011).
Bioecological Theory of Human Development
The theoretical framework chosen to guide this study was the PPCT model
described in Bronfenbrenner and Morris’ (2006) bioecological theory of human
development (BTHD). First, the rationale for selection of this theoretical model is
22
described. Chinn and Kramer’s (2015) process for the description and evaluation of a
theory was used to identify and explain the theoretical purpose, key definitions,
constructs, relationships, structures, and assumptions of the BTHD theory
(Bronfenbrenner & Morris, 2006). A diagram illustrating the theoretical model based on
the researcher’s understanding of the theory was developed (see Figure 1).
Figure 1. Bioecological theory of human development (Bronfenbrenner & Morris,
2006).
Rationale for Theory Selection
Following an extensive review of the literature related to student engagement in
PMH and nursing home CLEs and learning or competency development, the PPCT
model was chosen because its grand theory offered a parsimonious, deceptively simple
framework to organize findings from the studies in the literature review due to the
dynamic, interactional connections and mechanisms within the model. A complex,
Figure 1. Bioecological Theory of Human Development (Bronfenbrenner & Morris, 2006)
Personal Characteristics
Personal Characteristics
Disposition Resource Demand
PROXIMAL PROCESSES
Interactions with People
Interactions with Objects/Ideas
PRODUCER
PAST PRESENT FUTURE
DYSFUNCTION --
-
COMPETENCE +
23
interactional model was essential due to the levels of complexity inherent within the
concepts of (a) CLEs, (b) competency development, and (c) student engagement in
learning. Therefore, a grand theory was needed that could provide a broad framework to
allow for explanation and prediction of how multiple concepts were expected to interact.
For example, the CLE has been defined as “the social interactions, organizational
cultures and structures, and physical and virtual spaces that surround and shape
participants’ experiences, perceptions, and learning” (Josiah Macy Foundation, 2018, p.
35). The CLE is an interactive network of forces within the clinical setting that
influences students' learning outcomes (Chan, 2002, p. 70). Competencies are defined as
“a complex know-act that is based on combining and mobilizing knowledge, skills,
attitudes, and external resources and then applying them appropriately to specific types of
situations” (Canadian Association of Schools of Nursing, 2015, p. 8). Student
engagement has been defined as
a dynamic reiterative process marked by positive behavioral, cognitive, and
affective elements exhibited in pursuits of deep learning. This process is
influenced by broader contextual preconditions of self-investment, motivation,
and a valuing of learning. Outcomes of student engagement include satisfaction,
sense of well-being, and personal development. (Bernard, 2015, p. 1)
In addition, the bioecological theory of human development was well suited to
guide nursing leadership efforts aimed at creating desired health and nursing education
outcomes through identification of contextual factors from micro- to macro-levels to
guide research, policy, and practice (Chinn & Kramer, 2015; Onwuegbuzie, Collins, &
Frels, 2013). These characteristics aligned well with this study’s’ goal of creating
24
preferred clinical educational experiences through change. The ability to systematically
identify and analyze contributing factors to explain why student experiences in inpatient
mental hospitals and in nursing homes were not valued as highly as clinical learning in
acute care hospitals was a necessary first step before alternate clinical designs, policies,
and practices could be envisioned. The philosophical view of this theory called for
mixed methods designs where empirical and naturalistic observations, interviews, focus
groups, and field diaries were compatible methodologies. This philosophical stance was
also compatible with the nature of the discipline of nursing (Chinn & Kramer, 2015).
Purpose and Definitions
Bronfenbrenner was a developmental psychologist. The bioecological theory of
human development (Bronfenbrenner & Morris, 2006) represents the most current form
of Bronfenbrenner’s evolving theoretical system that aims to provide a framework for the
scientific study of human development over time. The phenomenon of human
development was defined by Bronfenbrenner and Morris (2006) as “stability and change
in the biopsychological characteristics of human beings over the life course and across
generations” (p. 766).
The word bioecological was chosen to show how human organisms both affected
and were affected by their biology and environments. Bio- refers to the biological and
evolutionary processes that set limits and imperatives for realization of human potential.
To the extent that conditions and experiences for development are not provided, human
potential remains unactualized (Bronfenbrenner & Morris, 2006). Ecological refers to
the importance of studying human development in the ecological contexts in which it
25
occurs (Bronfenbrenner & Morris, 2006). The overarching purpose of the BTHD was to
fulfill two broader but interrelated objectives:
1. Devise new alternative hypotheses and corresponding research designs that
not only question existing results but yield new, more differentiated, more
precise, replicable research findings, and thereby produce more valid
scientific knowledge.
2. Provide scientific bases for the design of effective social policies and
programs that counteract newly emerging developmentally disruptive
influences. (Bronfenbrenner & Morris, 2006, p. 795)
It is important to realize that this theory has evolved over time in three phases of
development from 1973 to present day. According to Rosa and Tudge (2013), in the first
phase (1973-1979), conceptualizations were focused on different contextual levels that
exerted influence on the development of a person. In the second phase (1980-1993),
focus was on how the environment impacted human development by analyzing how
existing person-environment theories applied to Bronfenbrenner’s model. In the third
phase (1994-2006), the theory received its current name of the BTHD and was
characterized by the formulation of the PPCT model.
Major Constructs in the Theory
The four major constructs in the PPCT model are process, person, context, and
time.
Process. The central construct is process, which Bronfenbrenner and Morris
(2006) called proximal processes. Proximal processes are defined as interactions
between the human organism and environment over time. Proximal processes are posited
26
to be the primary mechanism producing human development (Bronfenbrenner & Morris,
2006). As seen in Figure 1, proximal processes are central to the model; persons and
environment are discrete, yet overlapping constructs that contribute to human
development.
Important assumptions concerning the proximal processes are that for
development to occur, people must engage in activities. These activities must occur on a
fairly consistent basis over time and cannot be interrupted frequently. The activities
should become increasingly more complex in nature. Activities with other persons,
objects, and ideas or symbols are key drivers of human development. In this model, both
relational interactions through interpersonal activities and solo activities involving
interactions with objects and ideas (tasks) are important in human development. The
interactional quantity and quality of the proximal processes contribute to whether good or
poor developmental outcomes occur; therefore, outcomes associated with the proximal
processes are whether they are generative (positive) or disruptive (negative). Generative
processes result in competency and disruptive processes result in delayed development or
disability. Application of this construct to studying student nurse development of PMH
competencies in a CLE would hypothesize that student nurses develop higher levels of
PMH competency in CLEs where there is adequate time to be exposed to good quality
opportunities to experience positive interactions with appropriate persons, ideas, and
objects related to PMH nursing.
While the proximal processes are central to the BTHD (Bronfenbrenner & Morris,
2006), the power of the proximal processes to influence human development varies
substantially as a function of the characteristics of the developing person, the immediate
27
and more remote environmental contexts, and the time periods in which the proximal
processes take place (p. 795). Each of these remaining constructs is now discussed in
order.
Person. The construct of person is conceptualized as being both a producer and
product of human development that operates in an input-output type of structure with
inter-relationships to and from the proximal processes. This relationship means the
characteristics of a person could determine the form, power, content, and direction of the
proximal processes.
The construct of person has three characteristics that impact the person’s ability to
engage in the proximal processes, thereby influencing later development: dispositions,
resources, and demands. In the bioecological model, the characteristics of the person
“most likely to influence future development are active behavioral dispositions that can
set the proximal processes in motion or – conversely – actively interfere with, retard, or
even prevent their occurrence” (Bronfenbrenner & Morris, 2006, p. 810). The BTHD
model characterizes the propensities of the dispositions as being either developmentally
generative or developmentally disruptive. Examples of developmentally disruptive
dispositions are characteristics such as “impulsiveness, explosiveness, distractibility,
inability to delay gratification at one pole to personal attributes of apathy, inattentiveness,
unresponsiveness, lack of interest, insecurity, shyness, or the tendency to withdraw from
activities at the other pole“ (Bronfenbrenner & Morris, 2006, p. 810). Resources are
defined as abilities, experiences, knowledge, and skills required for the effective
functioning of the proximal processes (Bronfenbrenner & Morris, 2006). Demand
characteristics “invite or discourage reactions from the social environment that can foster
28
or disrupt the operation of proximal processes” (Bronfenbrenner & Morris, 2006, p. 796).
This means a students’ behavior could elicit positive or negative responses from others,
thereby influencing whether their future course of development is generative or
disruptive.
Application of the person construct to clinical nursing education is readily
apparent when considering how often nurse educators observe that non-academic
personal characteristics besides grade point average and performance on standardized
tests might be more influential in determining whether or not a student would make a
good nurse and whether or not they would be successful in completing the nursing
education program. However, very little research established what those personal
characteristics were (Pugachov, Maxwell, Youmans, & Wahnschaff, 2015).
Context. The construct of context was the central construct in the original
ecological systems theory (Bronfenbrenner, 1979). The purpose of the theory at that time
was to explain how everything in a child's environment affected how a child grew and
developed. The theory was found to have applications to human development across the
lifespan and was widely used in research involving the study of children as well as adults.
Five levels of the environment that influence development are the microsystem,
mesosystem, exosystem, macrosystem, and the chronosystem. Bronfenbrenner
(Bronfenbrenner & Morris, 2006) described the structure and inter-relationships of the
five levels as a nested model, similar to a set of Russian nesting dolls. The microsystem
is the one closest to a person and the one with which a person would have direct contact
(“Bronfenbrenner's ecological systems theory,” 2018). For a child, the people and
organizations they interact with on a frequent basis such as parents, siblings, day care,
29
school, and sports teams compose the microsystem. Interactions in the microsystem are
bi-directional, i.e., the way people treat the child affects the child’s development and
likewise the nature of child’s interactions with these people affects how they treat the
child (Bronfenbrenner & Morris, 2006). For a baccalaureate nursing student, the
microsystem might include their parents, siblings, peers, home, dorm, the nursing
classroom, CLE, nursing faculty, and clinical nurses.
The mesosystem was defined by Bronfenbrenner (1979) as “the interrelations
among two or more settings in which the developing person actively participates such as,
for a child, the relations among home, school, and neighborhood peer group: For an adult,
among family, work, and social life” (p. 25). In other words, the mesosystem refers to
relations among microsystems or connections among contexts such as the relationship
between family experiences and school experiences, between school experiences and
neighborhood experiences, and between family experiences and peer experiences
(Onwuegbuzie et al., 2013). In clinical education, examples of mesosystem influences
might include interactions between how classroom theory and clinical education are or
are not adequate to promote PMH competency development or how the quality and level
of collaboration between clinical instructors from practice and academia could impact
student development either negatively or positively. Indeed, these factors were reported
in the literature reviewed as contributing factors to learning and competency development
outcomes for student nurses.
The exosystem refers to “linkages and processes taking place between two or
more settings, at least one of which does not contain the developing person, but in which
events occur that indirectly influence processes within the immediate setting in which the
30
developing person lives” (Bronfenbrenner, 1993, p. 24). For example, in clinical
education, rules imposed by the hosting clinical organization require that students
complete mandatory online onboarding processes before attending clinical education.
This is an example of an exosystem—the nursing student is not in direct contact with but
yet the influences of this system could have a complex effect on the student’s daily life
and emotions. Onboarding processes can often be extensive, requiring students to
complete multiple learning modules, pass online quizzes, and submit immunization
records with firm deadlines. If nursing students are disciplined by their academic
instructor for not completing required clinical onboarding activities by the deadline, they
might experience negative emotions toward the clinical experience and might cause them
to be disengaged from participating in clinical activities, which would result in not doing
well in the course and reinforcing a dislike for the particular clinical experience.
The macrosystem, the most distant level from the developing person, involves a
larger cultural context (e.g., society, community) surrounding the person that includes
societal belief systems, cultural norms, ideologies, policies, or laws that indirectly
influence the person. Macrosystems evolve over time, are representative of institutional
systems of a culture, and are related to economic, social, educational, legal, and political
aspects (Bronfenbrenner, 1979). In a study of nursing student experiences in inpatient
mental health hospitals and nursing homes, application of the BTHD (Bronfenbrenner &
Morris, 2006) might lead to hypotheses that part of the reason why students perceived
they would not like working in a nursing home or mental hospital was due to
macrosystem influences such as negative media reports, movie images, and the stigma
surrounding mental illness and ageism.
31
Time. Later, Bronfenbrenner (1979) added another concept (the chronosystem)
that represented the effect of time on human development. The chronosystem is
composed of environmental and sociohistorical events that occur in a persons’ lifetime
(“Bronfenbrenner's ecological systems theory,” 2018). The construct of time in the
PPCT model explains how systemic interactions in an individual’s life time over time and
across generations shape development. An example of time in the chronosystem in this
study was seen by considering that attitudes of nursing students today toward the elderly
and mentally ill were influenced by, yet different from past generations. Individuals and
generations have perspectives on issues that are similar and different based on shared and
differing experiences of environmental and sociohistorical events. Another example to
illustrate these concepts would be to reflect on how nursing values that persist today
might have roots in events in the distant past. Yet, these experienced events continue to
shape the development of nursing in present time.
In the next sections, literature from 2009 to 2019 related to student engagement in
CLE, and learning experiences in nursing homes, and inpatient mental health hospitals is
discussed.
Student Engagement in Clinical Learning Environments
Learners’ levels of engagement with the curriculum and the extent to which they
chose to interact with learning activities were well supported in the educational literature
as being a necessary prerequisite for learning and competency development to occur
(Dewey, 1933; Kolb, as cited in Newton et al., 2009; Rogers, 1967; Schon, as cited in
Wang, Qiao, & Chui, 2018). Nursing students’ ability to transfer what they learned in
university classrooms and skills labs to clinical practice was dependent on personal,
32
social, and environmental factors with student engagement being a key factor that
expediated classroom and skills laboratory learning to CLEs and thus promoted better
transition to practice, leading to decreased nursing attrition and better patient care
outcomes (Hudson, He, & Carrasco, 2019; Newton et al., 2009). Rather than viewing the
theory-practice gap as a gap between the inter-related socio-cultural contexts of practice
and academia, Newton et al. (2009) stated the contexts were parallel, not inter-related,
which required students to translate the values and beliefs inherent in dissimilar contexts,
resulting in learning that was ‘lost in translation.’
Wang et al. (2018) reported four interrelated aspects of student engagement were
significantly related statistically with academic achievement in higher education: (a)
behavioral engagement characterized by students being actively involved in their
learning, (b) emotional engagement characterized by student possession of emotions that
facilitated learning tasks, (c) cognitive engagement where students used sophisticated
learning strategies, and (d) agentic engagement where students actively sought learning
opportunities rather than passively receiving them (Wang et al., 2018). This focus on
learner dispositions, resources, and demands was a key construct in the PPCT model as
well (Bronfenbrenner & Morris, 2006). Most studies of student learning in clinical
education focused on social and environmental factors that either promoted or impeded
learning and competency development. The findings of Newton et al. (2009) and Wang
et al. (2018) demonstrated the need for more research into how personal characteristics
related to student engagement impacted learning during clinical education.
According to Irby (2018), a pressing interest to improve CLEs for health care
professionals exists today due to alarming increases in clinician burnout. Student
33
engagement was also posited to be protective against stress and burnout (Bernard, 2015;
Bruce et al., 2010). In a longitudinal, cross sectional survey of 1,702 Swedish nursing
students, Rudman and Gustavsson (2012) found student levels of burnout increased
significantly (from 30% to 41%) across three years of nursing education with significant
increases in exhaustion and disengagement (p < .001). Follow-up at one year post-
graduation, earlier development of study burnout was associated with lower mastery of
occupational tasks and higher turnover intentions (Rudman & Gustavsson, 2012).
Far less research has been conducted to understand the relationships between
learning and student engagement in CLEs than has been conducted for classroom
environments in higher education. A search of CINAHL and Medline conducted on
November 3, 2019 using the key words student engagement in learning AND clinical
education OR clinical learning environments located 37 studies. Inclusion criteria were
research, English, and peer-reviewed articles from 2009 to 2019. When exclusion criteria
of clinical learning through simulation studies that did not include undergraduate students
were applied, 13 studies were identified.
Baccalaureate Student Nurse Experience
in Nursing Homes
Factors influencing student learning in nursing homes were grouped under the
categories of the PPCT model that guided this study (Bronfenbrenner & Morris, 2006).
Person
Evidence showed nursing students held negative attitudes toward clinical
placement in nursing homes, viewed staff working in LTC as inferior, and assumed they
would learn less in nursing homes than in acute care hospitals (Annear, Lea, & Robinson,
2014; Banning, Hill, & Rawlings, 2006). Many studies were conducted to understand
34
how student attitudes toward older adults contributed to their interest in a future career in
gerontology nursing (King, Roberts, & Bowers, 2013). Studies focused on evaluating
student nurse trends in (a) attitudes alone, (b) preferences alone, or (c) both attitudes and
preferences toward working with older adults (King et al., 2013). King et al. (2013)
reported that research regarding students’ preferences and attitudes were inconclusive.
Some studies reported improved student attitudes and preferences to work in nursing
homes after exposure to working with elders gained through classroom theory and
clinical experience, other studies found students had more negative views after clinical
experience in nursing homes, and others found no change at all (King et al., 2013).
Husebø et al. (2018) found students who viewed nursing homes negatively tended to
view the CLE negatively (Abbey et al., 2006; Banning et al., 2006; Brynildsen, Bjørk,
Berntsen, & Hestetun, 2014; Xiao, Kelton, & Paterson, 2012), whereas students
possessing prior interest in working with elders rated the clinical experience more highly
(Carlson & Idvall, 2015). A body of evidence indicated student placement in nursing
homes positively affected students’ attitudes toward nursing home care with the
discovery that caring for elders could be enjoyable (Abbey et al., 2006; Annear et al.,
2014; Banning et al., 2006; Carlson & Idvall, 2015; Grealish, Lucas, McQuellin, Bacon,
& Trede, 2013). Salamonson et al. (2015) found English language learners and students
with prior work experience in nursing homes were less satisfied with their clinical
learning in nursing homes. Bjørk et al. (2014) found older students had significantly
more positive views of the CLE.
35
Process
Interactions with clinical instructors, preceptors, and other staff. Many
studies supported that high-quality preceptorship relationships, an arrangement in which
staff nurses worked with and taught student nurses in the clinical setting, were essential
to creating a satisfying clinical learning experience for students (Berntsen & Bjørk, 2010;
Carlson & Idvall, 2014; Husebø et al., 2018). Good preceptors were welcoming,
experienced, and knowledgeable, enjoyed their work, wanted to work with students,
found workplace learning opportunities for students to engage in, and role-modeled
excellent patient care (Husebø et al., 2018). Professional dialogue and reflection with a
preceptor or clinical instructor in post-clinical debriefing were additional interactive
strategies students reported improved their learning (Skaalvik, Normann, & Henriksen,
2012). In contrast, poor quality preceptors were not welcoming, ignored students, or
gave poor quality care. In nursing homes, witnessing poor quality care could cause
nursing students to experience moral distress and distance themselves from the clinical
experience (Clarke, 2015). Frequent changes in staff nurses who served as clinical
preceptors was another barrier to learning, probably because it disrupted the opportunity
to build a trusting relationship (Clarke, 2015).
Adequate supervision was identified as a primary influencer on learning in most
of the studies reviewed. Ensuring adequate supervision for BSN students is a problem in
nursing homes in the United States because typically, nursing assistants and licensed
practical nurses or two-year program associate degree nurses provide direct patient care
while baccalaureate and advanced practice nurses are in managerial or nurse practitioner
roles. Clarke (2015) found students viewed the roles between nurses and nursing
36
assistants in nursing homes to be rigid, clearly identified, and silo-ed. Brynildsen et al.
(2014) concluded academic-practice collaboration was needed to develop appropriate
supervision models and build on existing potentials to overcome barriers that appeared to
be more unique to nursing homes than other healthcare settings.
A strength present in many nursing homes in the United States has been the use of
interdisciplinary team models of care that provided good opportunities for students to
learn interprofessional team work and greater understanding about the scope of practice,
roles, and responsibilities of various healthcare team members (Huls, Rooij, Diepstraten,
Koopmans, & Helmich, 2015; Mezey et al., 2009). The role of the academic clinical
instructor was discussed by Struksnes et al. (2012). In this qualitative study, group
supervision of the staff nurses in nursing homes by an academic clinical instructor along
with written information from the university college provided staff nurses with increased
assessment and teaching skills to supervise clinical nursing students. This relationship
strengthened the collaborative partnership between practice and academia (Struksnes et
al., 2012).
Interactions with peers. Students attending clinical in nursing homes where peer
partnerships existed between first- and third-year nursing students expressed high
satisfaction with the use of cooperative peer learning as an instructional strategy that
increased student learning in clinical settings (Brynildsen et al., 2014). Lea (2014) also
found students highly valued peer relationships in nursing home settings. More research
is needed about how peers could be used to improve clinical learning in nursing homes.
Interactions with patients. Studies reported that novice students were often
unprepared and unsure about how to interact and care for elders in nursing homes,
37
especially when they had challenging behaviors due to dementia (Xiao et al., 2012).
More research is needed about how patients affected students’ learning in nursing homes.
Interactions with objects and ideas (tasks). Students reported that access to
information and preparation attained through adequate classroom theory, effective
pedagogical approaches, and a well-planned orientation prior to clinical placements
contributed to more positive CLEs (Bisholt et al., 2014; Chan, 2002). Cross-sectional
studies using the CLEI-A for student survey of the CLE found nursing students
consistently rated innovative clinical teaching the lowest of all the subscales measured
(Chan, 2002). Many high quality and innovative educational materials, competency
standards, and lesson plans are provided online that clinical instructors and nurse
educators could use to implement student nurse and staff development but it was not clear
how many programs utilized these readily available resources. Inserting more geriatric
education and clinical experiences with elders into the nursing curriculum and more
training, especially in mental health care, for students and nursing home staff would
likely improve the quality of care in nursing homes and the CLE as well (Beck,
Buckwalter, Dudzik, & Evans, 2011).
Opportunities to perform varied and meaningful tasks are important to learning
and student satisfaction (Bisholt et al., 2014). Students rated acute care hospitals as
having more meaningful learning opportunities than nursing homes or mental health units
(Bisholt et al., 2014). However, other studies reported creative ways to improve student
engagement in learning in LTC. Skaalvik et al. (2012) found that having students give
handoff reports between shifts was viewed as a meaningful learning experience. Being
included as part of the interprofessional team along with access to staff, faculty members,
38
and peers to discuss and reflect on the care of older people were valuable learning
experiences reported across several studies (Huls et al., 2015; Mezey et al., 2009;
Skaalvik et al., 2012).
Context
Husebø et al. (2018) identified the nursing home ward environment as a
significant theme in the literature from 2005-2015. Studies suggested nursing homes
were ideal CLEs for nursing students due to the warm and welcoming environment,
friendly staff, and slower pace of care as compared with acute care settings (Chen,
Brown, Groves, & Spezia, 2007; Lea, 2014). A variety of patients and medical
conditions facilitate learning (Brynildsen et al., 2014). The presence of patients with
mental health conditions was not identified as being a learning opportunity in any of the
studies even though statistics supported that as many as two-thirds of residents in nursing
homes had diagnosable mental health conditions (APA, 2019). Factors that negatively
influenced student learning included short staffing, leaders who were unsupportive of
staff, nursing students’ reluctance to work with nursing assistants, and a lack of resources
as compared to hospital settings (Abbey et al., 2006; Robinson, Andrews-Hall, & Fassett,
2007; Skaalvik et al., as cited in Husebø et al., 2018). A lack of human resources in
nursing homes was mentioned in several studies but more information is needed about
how material resources such as space for post-conferences, access to computers, and use
of technology contribute to the CLE.
Time
The timing of student participation in nursing homes for clinical practice is
generally early in a nursing student’s educational program, often in the first or second
39
semester in the program, and most often to practice basic communication and
fundamental nursing skills (Berntsen & Bjørk, 2010; Melillo et al., 2014). However,
nursing care in the LTC setting is complex due to the complicated blend of physical and
emotional care needed to manage chronic health care conditions and psychosocial aspects
of aging such as loss of previous levels of physical and cognitive function, challenging
behaviors, and relocation to institutional systems of care (Berntsen & Bjørk, 2010;
Carlson & Idvall, 2014). This mismatch between the complexity of the CLE and the
inexperience of the nursing students might be a factor that has contributed to student
anxiety and dislike of LTC as a clinical setting (Carlson & Idvall, 2015). Bisholt et al.
(2014) said educators must evaluate whether the setting offers students a meaningful
learning environment where the desired learning outcomes might be achieved. This
would require timing the scaffolding of clinical learning experiences. Another negative
influencer reported by students was not enough time with preceptors or mentors (Clarke,
2015).
Competency Development in Nursing Homes
Chen et al. (2007) found 83% of nursing education programs surveyed (n = 53)
used nursing homes as clinical settings to teach fundamentals of nursing, physical
assessment, and communication skills. Mezey et al. (2009) conducted a quality
improvement study to describe and identify terminal learning competencies developed by
students in five geriatric clinical health care specialties (dentistry, medicine, nursing,
social work, and pharmacy). The goal of their study was to understand more about the
strengths and limitations of the nursing home CLE as supporting professional
competency development for both BSN and advanced level healthcare training. The
40
study found all five professions used nursing homes as clinical sites for advanced level
training. Core geriatric nursing skills for baccalaureate nurses included interprofessional
team skills, practice across the continuum of care, and all levels of wellness. Other
competencies identified were nursing process (opportunities for assessment, diagnosis,
care planning, implementation and evaluation), professional role, advocacy, health
teaching, bereavement support, cultural competence, and better understanding of how to
facilitate transitions between levels of care (Mezey et al., 2009).
Huls et al. (2015) conducted a qualitative study that included open-ended survey
questions followed by focus groups to explore medical student perceptions of their
learning outcomes in nursing homes. Participants reported learning in nursing homes
differed from learning in the hospital in three primary ways: (a) interprofessional
collaboration was more prominent, (b) less resources in nursing homes stimulated
creativity, and (c) students had more autonomy and less educational guidance (Huls et al.,
2015). No studies were located that studied the development of PMH competencies in
nursing homes even though development of communication, therapeutic relationship
skills, and interprofessional collaboration are important components of PMH
competency. Husebø et al. (2018) summarized that competencies achieved in nursing
homes included increased basic nursing skills, greater knowledge of ageing and
gerontology, and a change in attitude in caring for older people.
Baccalaureate Student Nurse Experience
in Inpatient Mental Hospitals
Factors influencing student learning in inpatient mental health hospitals were
grouped under the categories of the PPCT model that guided this study (Bronfenbrenner
& Morris, 2006). There was a scarcity of evidence about the student nurse experience in
41
PMH inpatient mental health units from the perspective of the quality of the CLE and
factors such as how time, teaching strategies, and models of supervision impacted PMH
competency development (Happell, 2008b). Additionally, studies had not controlled for
the type of experience (Happell, 2008b). Many studies addressed student anxiety about
attending mental health clinical, a factor that might promote more positive attitudes
toward PMH nursing and mental illness (Choi et al., 2016; Demir & Ercan, 2018).
Person
`Personal characteristics of student nurses that impacted learning in inpatient
mental health settings were anxiety (Boardman, Lawrence, & Polaschek, 2019; Demir &
Ercan, 2018), having a mental health condition or a family member with a mental health
condition (Demir & Ercan, 2018), age, gender, and previous work experience in mental
health (Happell, 2008b).
Process
Interactions with clinical instructors, preceptors and other staff. Some
studies reported students generally were happy with their mental health placements and
felt welcomed and supported by preceptors (Happell, 2008b). Other studies reported
student experiences in mental health clinical in a more negative light, citing factors such
as being ignored by registered nurse (RN) preceptors (McKinney et al., 2016) and
witnessing standards of care not compatible with what was being taught in university
classrooms and skills labs, resulting in moral distress for nursing students (Slemon,
Bungay, Jenkins, & Brown, 2018).
Similar to findings in nursing homes, the role of the clinical practice nurse as
preceptor is essential to student learning. Some of the barriers to effective interactions
42
between the students, preceptors, and teachers included a lack of structure and
information provided in preceptor meetings, few lectures provided by teachers requiring
students to learn information on their own, and poor communication between academia
and practice that resulted in conflicts and rumors between these two groups (Grav et al.,
2010). Other negative processes that were disruptive to learning and competency
development were reported to occur when students were partnered with many different
staff RN preceptors instead of one or two main teachers and when nurse preceptors had
little to no training in how to teach or supervise the students (Carrigan, 2012).
Interactions with peers. No studies in the review addressed the role of peers in
the inpatient PMH CLE.
Interactions with patients. Direct interactions with patients on PMH units were
influential in replacing students’ fear and anxiety about PMH clinical with feelings of
empathy, decreased stigma, and increased confidence to work with PMH patients (Demir
& Ercan, 2018). Conversely, anxiety could prevent students from interacting with PMH
patients, causing them to distance themselves from the patients and not interact with
them, preferring to use the electronic health record for patient information (Karimollahi,
2012).
Interactions with objects and ideas (tasks). Theory is reported to be a
necessary but not sufficient means for students to develop PMH competency or decreased
stigma (Demir & Ercan, 2018; Happell, 2009). Clinical experience in mental health
sectors provides opportunities with students to observe experts in PMH engaged in
meaningful tasks and participate in those tasks (Barrett & Jackson, 2013; Happell &
Platania-Phung, 2012).
43
Context
A goal of this study was to better understand the evidence for best practices in
selecting a favorable clinical setting in which nursing students could develop PMH
nursing competencies. Due to the widespread incidence of mental illness across
populations, one hypothesis was PMH competencies could be learned in any setting
where interaction with people with mental illnesses was possible. Happell and Platania-
Phung (2012) reported clinical placements in non-mental health settings did not appear to
favorably influence students’ attitudes toward mental health nursing despite mental
illnesses being common in these settings. The researchers concluded clinical placements
in mental health settings were essential for undergraduate nursing students to develop
more positive attitudes toward persons with mental illness and toward mental health
nursing, a necessary requisite to achieving nursing competency.
Barrett and Jackson (2013) discussed Jackson’s experiences as a nursing student
attending a 150-hour placement in a mental health charity providing community support
to persons with schizophrenia. Jackson’s perception of this experience was it was like
“learning to swim without the water” and concluded that when clinical experiences were
separated from the context of practice, improved appreciation for mental health and
persons with mental illness could be gained but it was difficult to apply theoretical
knowledge and gain new skills in settings where one’s role was not clear and professional
role models were unavailable (Barrett & Jackson, 2013). Fiedler, Breitenstein, and
Delaney (2012) found that students in community mental health placement sites were less
confident in medication administration and de-escalation following a PMH clinical
practicum.
44
Time
Timing is another important factor in mental health clinical learning, requiring
further exploration to build best practice for positive student learning outcomes and
competency development (Happell, 2008b). Fiedler et al. (2012) found students in an
accelerated program who spent one-third less time in the PMH clinical practicum than
traditional program students had no significant difference between groups in students’
confidence ratings. This finding was consistent with previous research (Happell, Robins,
& Gough, 2008) that reported time spent in clinical did not significantly influence
acquisition of clinical competencies or perceived preparedness. Boardman et al. (2019)
explored whether students would perceive better learning by attending clinical once a
week for eight hours for 16 weeks while concurrently having classroom theory on PMH
or by attending clinical five days a week over one month. The study found that moving
between the classroom and clinical over an extended time period allowed better
application of theory to practice, more time to learn new tasks, and reflection on practice
(Boardman et al., 2019).
Competency Development in Inpatient
Mental Health Units
For students, links between attending clinical education in a mental health
practice setting and subsequent improvements in PMH nursing competencies were well
supported by the literature (Fiedler et al., 2012; Happell, Gaskin, Byrne, Welch, &
Gellion, 2015). Situated learning with opportunities for students to practice PMH skills,
receive feedback, and observe role modeling by experienced PMH nurses and
interprofessional team members contributed to student nurse competency development
(Callaghan, Cooper, & Gray, 2007; Happell et al., 2015; Ross, Mahal, Chinnapen, &
45
Rana, 2013). There were rich opportunities to observe and practice specific PMH
nursing skills such as psychosocial and mental status assessment, knowledge of
psychotropic medications, de-escalation, management of psychosis and hallucinations, as
well as knowledge and skills generalizable to all nursing care, especially therapeutic
communication and relationship-building (Fiedler et al., 2012; Happell et al., 2015;
Henderson, Happell, & Martin, 2007).
Clinical education in inpatient mental health units was also associated with more
positive changes in student attitudes, anxiety levels, and confidence to work with patients
experiencing mental illness (Feeney, Jordan, & McCarron, 2013; Fiedler et al., 2012;
Happell, 2008a; Thomas & Bhattacharya, 2012). Numerous studies concluded that
student nurses experienced high levels of stress and anxiety prior to attending clinical on
inpatient mental health units due to factors such as stigma and perceptions of persons
with mental illness as being aggressive and unpredictable (Thomas & Bhattacharya,
2012). Direct contact with patients on mental health units allowed student nurses to
develop more realistic and positive views of people with mental illness as being “just
people” who were sick and required skilled and compassionate nursing care (Demir &
Ercan, 2018). Students also reported personal growth after attending mental health
clinical on inpatient units including more tolerant views about human diversity and
greater acceptance of the limitations of self and others (Demir & Ercan, 2018).
Fiedler et al. (2012) developed a student nurse PMH competency scale by using
The Essentials Document developed by nursing educators and PMH experts that outlined
16 PMH skills considered to be essential for entry-level nursing practice (American
Psychiatric Nurses Association, International Society of Psychiatric Mental Health
46
Nurses, & American Nurses Association, 2014). The 16 competencies were matched
with Likert-type response options that asked students to rate their confidence in
performing each of the 16 skills from 1 (Not at all confident) to 5 (Totally confident).
The following open-ended questions were added to the survey:
1. Are there any additional skills you wished you had more experience with?
2. Other than your instructor, were there nursing role models in your area that
helped clarify your role?
3. Do you feel you understand the psychiatric-mental health role?
Responses to these questions were reviewed to support the quantitative findings.
Fiedler et al. (2012) concluded that measuring competencies could be used to track which
learning climates helped develop desired knowledge, skills, and attitudes. Competency-
based education could free faculty from “the traditional model of clinical education
where skill development depended on random access to learning opportunities” (Gudrun,
Howe, & Schoessler, as cited in Fiedler et al., 2012, p. 248) and resulted in movement to
a more planned approach to providing experiences necessary to reach specific outcomes
and competencies (Fiedler et al., 2012).
Conclusion
Studies related to CLEs in inpatient mental health units and in nursing homes
showed similarities and differences between the two settings existed. Students were
generally satisfied with their placements in inpatient mental health and nursing homes but
there was room for improvement (Carlson & Idvall, 2014, 2015; Happell et al., 2015).
Stigma and ageism are discriminatory attitudes that might be present in both settings. In
both settings, witnessing poor standards of care delivery by nursing staff resulted in
47
moral distress for nursing students. This finding highlighted the requisite for students to
observe high quality care and to work with nursing staff that was enthusiastic and expert
in care delivery. Due to negative perceptions, students reported initial anxiety or
dissatisfaction that tended to be replaced by more positive attitudes toward the patient
population by the end of the clinical experience (Grav et al., 2010; Karimollahi, 2012).
Both mental health units and nursing homes prioritized use of the interprofessional health
team for care provision, thereby optimizing opportunities for students to observe and
participate in interprofessional activities.
Factors that appeared to optimize student learning and competency development
across settings were (a) adequate student preparation for the clinical experience through a
well-planned orientation to the clinical site, sufficient theory, and skills practice to be
able to safely apply knowledge and skills to patient care; (b) a supportive clinical
environment characterized by mutual recognition, respect, and welcoming attitudes
between students, clinical nursing staff, and academic clinical instructors; (c) good
communication and supportive relationships between clinical preceptors and academia
and use of clinical instructors as consultants to ensure clinical learning experiences are
underpinned by sound teaching-learning strategies; (d) adequate supervision of students
by qualified, experienced, and enthusiastic staff nurse preceptors and clinical instructors;
(e) access to meaningful, active learning opportunities with sufficient, appropriately
sequenced levels of challenge as students need to be able to perform and not just observe
skills; and (f) student awareness of their own personal characteristics that could promote
or impede their learning and competency development in clinical practicum, especially
their level of engagement in learning activities.
48
A main difference for students attending clinical in nursing homes and inpatient
mental health settings was access to resources. Similar to acute care hospital units,
inpatient mental health units most often have larger numbers of registered nurses
providing direct patient care on the units. This valuable asset enabled nursing students
access to preceptorships and role modeling by experienced PMH nurses that might not be
available in nursing homes. Likewise, greater access to material resources such as
conference rooms, computers, and meaningful learning opportunities related to PMH
nursing might be more present in inpatient mental health units than in nursing homes.
Gaps in the Literature
Prior studies of CLEs focused on learner perceptions of CLEs. Future studies
should elucidate elements that contribute to positive and negative learning environments
and include the voices of participants (Josiah Macy Foundation, 2018). Analysis of the
literature related to student engagement in interactions with persons showed many studies
had been conducted about the essential role of staff nurse preceptors and academic-
practice practice that correlated those factors with more positive CLEs. However,
noticeable gaps existed about what role interactions with the academic clinical nurse
instructor, peers, patients, interprofessional team members, and tasks in CLEs were
associated with more student engagement, better learning outcomes, and PMH
competence.
Interactions with persons, objects, and ideas were linked with more positive
developmental learning outcomes as were the use of active learning strategies
(Bronfenbrenner & Morris, 2006; Weimer, 2002). Clinical learning environments
provide students with an authentic milieu for active learning that should be engaging.
49
However, little research supported whether or not students were engaged in clinical
learning and how to measure that learning (Loch, 2013). Empirical studies and expert
experience supported the need to know more about how the person-process-context-time
variables that promoted and disrupted student nurse competency development and more
positive attitudes in PMH inpatient units and nursing homes. Results of this study could
add to the evidence base to inform new designs for clinical education models in PMH and
nursing homes that engage students’ interest in future careers to ease workforce shortages
of RNs to meet the physical and mental health needs of people with mental illness and
elders.
Summary
This chapter reviewed literature related to the concepts of (a) student engagement
in clinical learning, (b) student perceptions of learning and competency development in
nursing homes, and (c) student perceptions of learning and competency development in
inpatient mental health units. Theoretical frameworks underpinning previous studies as
well as the theoretical framework for this study were discussed. Results of the literature
review were summarized including gaps in research that guided considerations for
research design and supported the need for the study. In Chapter III, the methodology for
the study is explained including the research design, participants, data collection and
analysis for the quantitative and qualitative strands, and ethical considerations.
50
CHAPTER III
METHODOLOGY
Introduction
This chapter presents the methodology for the study. The research design,
participants, setting and sample, data collection and analysis plans for the quantitative
and qualitative strands, ethical considerations, and summary are discussed.
Research Design
This dissertation’s mixed methods, collective case study design was guided by the
PPCT model in Bronfenbrenner and Morris’ (2006) bioecological theory of human
development (BTHD). Case studies are useful when there is a need to explain, describe,
and explore events or phenomena in the everyday contexts in which they occur (Crowe et
al., 2011). Thus, this design was well-suited to the goals and context of this study. The
use of detailed case studies has a long tradition in medical and nursing clinical education
to teach students so this approach seemed familiar and relevant for research conducted on
clinical education in nursing. As a nurse educator and clinical instructor, this researcher
has been a participant observer of students in clinical settings as they worked to develop
their understanding of and competency in PMH nursing care. This researcher has been
very close to the everyday experiences of students in naturalistic clinical settings.
A collective case study design is one in which qualitative and quantitative data are
collected and analyzed concurrently or sequentially to generate multiple cases (Creswell
& Plano Clark, 2018). In this study, two cases were generated: Case 1—students
51
attending PMH clinical in inpatient mental health units, and Case 2—students attending
PMH clinical in a nursing home. A mixed methods, collective case study design fit the
purpose of the study to compare and contrast the similarities and differences that
occurred between the two groups.
The boundaries of the cases were baccalaureate student nurses attending mental
health clinical in one nursing program in the Midwest during 2018-2020. All the
participants were concurrently studying mental health theory over one or two semesters,
had simulation activities related to mental health nursing care, and attended a four-week,
16-hour total mental health clinical in a nursing home or inpatient mental health setting at
various times during the 2018 to 2020 time frame. The students in both settings were
accompanied to mental health clinical by an academic nurse educator with expertise in
PMH nursing. The ratio was one clinical instructor for six to eight students.
Context
The students attending PMH clinical in the nursing home could also be viewed as
an intrinsic case study that is undertaken to learn about a unique phenomenon (Crowe et
al., 2011). Because students do not typically attend mental health clinical in nursing
homes, an opportunity to explore and describe their experiences is warranted when they
do. The 2019-2020 students in the nursing home setting spent one to two days on a
dementia unit and at least two days on a unit with residents who did not have dementia
but rather had chronic physical and mental illnesses such as hypertension, type 2
diabetes, heart disease, arthritis, depression, anxiety, bipolar disorder, schizophrenia,
posttraumatic stress disorder, or traumatic brain injuries. The clinical staff and instructor
purposefully selected residents for the students to interact with who had a significant
52
mental health condition. Students also attended an interdisciplinary care conference,
conducted psychosocial interviews and mental status exams, and developed clinical
nursing care plans for several residents.
Students at the nursing home were included in other meaningful learning
opportunities that arose. For example, they gave flu shots, attended a trauma-informed
care seminar developed for staff, and worked with behavioral analysts to learn more
about responding to challenging behaviors. Students worked with the paraprofessional
certified nursing assistants (CNAs) when they initially met their resident. In the first
semester of the clinical, they assisted the CNA in giving care. Students were assigned
one resident and completed their assessments and care plan with that one resident.
In the second semester, students worked in pairs and were assigned four residents.
They were assigned to complete vitals, a head to toe assessment, a mental status exam,
and screening tools for each of the four residents. In dementia care, they completed the
Edinburgh Feeding Evaluation in Dementia Care (Stockdell & Amella, 2008) while
assisting the staff in feeding the residents. They also completed the Mini-Cog© (n.d.), a
three-minute screening tool to detect changes in cognition in older adults. For residents
who were more independent and communicative, the students completed the Geriatric
Depression Scale (Yesavage et al., 1983) and the Saint Louis University Mental Status
(SLUMS, 2019) Examination for dementia. The students were expected to document a
nursing note (data-action-response) for each resident and report from them to the nurse
manager before leaving the unit.
Even though student nurses did not work directly with the BSN or advanced
practice nurse preceptor, often they had brief opportunities to shadow the BSN nurse
53
manager and observe the baccalaureate nurse role. On three of the units, the male senior
RNs (similar to nurse mangers) took an active role in teaching the students and sought
meaningful learning opportunities for them each week.
As the academic clinical instructor in the nursing home, this researcher rotated
between three units where groups of two to three students were placed. Because students
were placed on the dementia units first where many residents had impaired
communication, this researcher included a role play. In the role play, students
interviewed this researcher in small groups to conduct their psychosocial interview and
mental status exam. This researcher was able to give students feedback on their
communication and assessment immediately. A one-hour post-clinical debriefing was an
established part of the experience each week.
This researcher has also taught as an academic clinical instructor and worked as a
staff nurse in the inpatient mental health unit attended by students in the other group.
Thus, she was very familiar with that context. Each student assigned to the inpatient
mental health units shadowed a staff RN preceptor. Some preceptors were two-year
(associate degree in nursing-prepared) RNs but most were BSN level. Students might
have had several different nurses as preceptors over the four weeks of clinical or could
have had a different nurse each week. Students completed the same clinical assignments
(psychosocial interview, mental status exams, and nursing care plans) as the students in
nursing homes. They rotated to a different adult unit to care for acutely mentally ill
patients each week. Students also observed therapeutic groups conducted by the
psychologist, social workers, nurses, and occupational therapists. As in the nursing home
54
setting, the clinical instructor was an experienced nurse educator and had previous
experience as a PMH nurse.
Both groups of students participated in approximately 30 hours of classroom
theory related to PMH nursing in weeks 2, 4, 8, 10, 11, and 12 of the fall semester and
weeks 5, 6, 10, and 11 of spring semester. Students also participated in seven hours of
simulation related to application of PMH content in their junior year. The mental health
clinical experience was 35 hours over four weeks including a three-hour orientation. This
was the only mental health clinical experience students received during their BSN
program. Table 1 presents the concepts in the curriculum.
Table 1
Psychiatric Mental Health Nursing Concepts
Concept Content
Stress & Coping Anxiety
Defense mechanisms
Crisis
Post-traumatic Stress Disorder
Mood & Affect Major Depression
Bipolar Disorder
Cognition Schizophrenia
Dementia
Delirium
Self-concept Identity, self-esteem, and body image
Addiction and substance use disorders
Personality disorders
Eating disorders
Therapeutic Communication Intention & Presence, Grounding
Motivational Interviewing
De-escalation techniques & limit-setting
Trauma-informed Care
Recovery focus
55
Research Participants
Quantitative Data Setting
and Sample
This was a convenience sample from a potential pool of 151 baccalaureate
nursing students (junior level, n = 88; senior level, n = 63) enrolled in a medium-sized,
faith-based university in a metropolitan area in the Midwest in 2019-2020. In this
nursing program, junior year is when students attend mental health clinical and learn
PMH theory. Half of the junior-level students (n = 44) attended mental health clinical in
an urban LTC facility for veterans and the other half (n = 44) attended clinical on
inpatient mental health units in a large urban hospital in fall 2019 or spring 2020
semesters. These undergraduate students were randomly assigned to one of two sites by
the clinical coordinator. They were 18 years of age or older with above average cognitive
skills. All of the participants were women, most were 21 to 26 years old, and
approximately 35% were women of color.
The junior-level students were recruited to participate in the quantitative and
qualitative phases of the study. For the qualitative one-on-one semi-structured
interviews, senior-level students were also recruited to participate (N = 63). These
students attended mental health clinical at the same inpatient mental health or nursing
home site during the 2018-2019 academic year and their perspectives were thought to
provide a richer reflection of their experiences over the year after their PMH clinicals had
been completed.
For the quantitative research questions, an a priori power analysis was conducted
using G*Power software to determine the appropriate sample size. For linear multiple
regression (Question 1) with two predictors with an effect size of 0.25, alpha of 0.05, and
56
a power of 0.8, a total sample size of 42 was needed. For repeated measure analysis of
variance (ANOVA), 34 participants were needed to detect a moderate effect of .25, with
an alpha of 0.05, and power of 0.8. The actual sample size was 37 participants due to a
shortened face-to-face experience secondary to the coronavirus lock-down. Table 2
presents the demographic variables for the quantitative sample.
Table 2
Demographic Variables for the Quantitative Sample
Demographics Groups
Mental Health
n = 16 (%)
Nursing Home
n = 21 (%)
Age 21-26 years old 15 (94) 20 (95)
27-40 years old 1 (6) 1 (5)
Prior work in
healthcare
None 1 (6) 3 (14.2)
In LTC 6 (37.5) 10 (47.6)
In MH 4 (25) 2 ( 9.5)
In other healthcare 4 (25) 1(4.7)
Missing 1 (6) 5 (24)
First language English 11 (68.75) 13 (62)
Other 5 (31.25) 8 (38)
N = 37
Qualitative Data Sources
and Participants
Eleven baccalaureate level nursing students were interviewed using a semi-
structured research protocol based on Bronfenbrenner and Morris’ (2006) PPCT model
(see Appendix F). Participants included eight junior-level students attending mental
health clinical during 2019-2020 on inpatient mental health units (n = 4) or a nursing
57
home for veterans (n = 4). Three participants were senior-level nursing students who had
attended mental health clinical in 2018-19 in the same agencies as the junior-level
students (inpatient mental health, n = 1; LTC, n = 2).
The purposeful sample was planned to include students who could best help
explain the quantitative data but the sample ended up consisting of student volunteers
who were able to be scheduled within the time frame for data collection. Six of the
students were interviewed face-to-face by the researcher or research assistant in a private
office on campus prior to March 13, 2020. Due to the COVID 19 pandemic and the
closing of the campus, an IRB amendment to conduct interviews using recorded Google
Hangouts was granted for interviews of the remaining participants. Two of the senior-
level students responded to an email recruiting participants for the study and volunteered.
One participant was purposefully recruited by the researcher and agreed to participate.
Data Collection and Handling
Quantitative Data Collection
and Handling
Institutional Review Board approval was granted from the University of Northern
Colorado for the exempt study (see Appendix A). Junior-level student nurse participants
were recruited during the second week of spring semester 2020 when all students were
present at their nursing interventions class on campus. The graduate research assistant,
whom the students had never met, provided the students with written instructions about
the study and the informed consent (see Appendix B). Students had the opportunity to
ask questions before signing or returning a blank consent form to the research assistant.
The informed consent form had two separate lines for participation or declining
participation. Students consented to:
58
1. Allow their previously completed de-identified quantitative data (pre-and -
post BHCC and -post only CLEI-A) results to be included in the study after
they completed mental health clinical and received their mental health
clinical grade.
2. Participate or decline inclusion in a one-on-one semi-structured interview to
be conducted in spring semester 2020 with the researcher or research
assistant, whomever the student chose, at a convenient time and agreed they
were willing to be re-contacted by the researcher for member checking.
Students who signed an informed consent to participate completed a paper
demographic data form at that time which was de-identified and linked to
the qualitative and quantitative data by the research assistant (see Appendix
E).
The research assistant (RA) was a graduate level nursing student in the Master of
Nursing entry level (MSN-EL) program. Her participation was sponsored through a
university grant that provided students with the opportunity to gain experience in
research. The RA had an undergraduate degree in exercise science, completed training to
conduct research ethically (CITI), and had prior experience conducting research with
professors at a state university in the Midwest. The RA was familiarized with the
purpose of the study and was trained by the researcher in appropriate techniques for
conducting qualitative research interviews using a semi-structured interview protocol.
Specific resources used to train the RA included (a) 12 tips for conducting a qualitative
research interview (McGrath, Palmgren, & Liljedahl, 2019) and (b) semi-structured
interview guidance for novice researchers (Whiting, 2008). The research assistant role-
59
played an interview with the researcher. The researcher provided feedback to ensure the
RA was well prepared to conduct qualitative interviews according to best practices. The
researcher also reviewed all transcripts of interviews conducted by the RA and provided
ongoing supervision as needed.
Completed electronic copies of the final BHCC and CLEI-A surveys were kept in
the university mental health theory course educational platform on the researcher’s
password protected work computer. The informed consents and demographic forms were
kept in a locked file cabinet in the researcher’s office for three years, then shredded.
Qualitative Data Collection
and Handling
Eleven interviews were recorded using Microsoft recording technology and the
voice recorder on the researcher’s and research assistant’s work computers or in Google
Hangouts. Student interviews ranged in length from 11 to 72 minutes. The average
interview lasted about 30 minutes. Six hours of interview data were collected.
The MP4 recordings were uploaded to Trint transcription software for
transcription. The researcher and RA de-identified and edited the transcripts, removing
all personal and contextual identifiers. The finished transcripts were uploaded to NVivo
12 software for qualitative analysis. The researcher created a code book based on the
PPCT model (Bronfenbrenner & Morris, 2006), which was shared with the RA. The
MP4 recordings were stored in a folder in Box, the university secure cloud-based files, on
the researcher’s password protected work computer. They will be retained for three years
and then deleted.
60
Data Collection Tools
Behavioral Health Care Competency
Measurement Tool
The BHCC is a 23-item Likert scale instrument developed by nurses from three
community hospitals in Southern California to evaluate hospital nurses’ perceptions of
their mental health nursing skills (Rutledge et al., 2012). The steps of the nursing process
and the situation-background-assessment-recommendation (SBAR) framework for
healthcare team communication (Institute for Healthcare Improvement, 2011) guided the
survey construction. Based on professional standards from the APNA (2012) and the
Emergency Nurses’ Association (2011; Rutledge et al., 2012), a literature review, and
expert opinion from nurses and nurse researchers, four subscales were formed: (a)
Resource Adequacy (four items), (b) Patient Assessment ( items), (c)
Practice/Intervention Competency (seven items), and (d) Psychotropic Recommendation
(two items). Responses to each item were scored on a 5-point Likert-type scale requiring
responses from 1—strongly disagree to 5—strongly agree. The higher the BHCC score,
the higher a respondent’s perceived behavioral health care competency (Rutledge et al.,
2012, p. 2759). The maximum score that could be attained was 110.
From the original 31-item scale, a 23-item scale was developed. Cronbach’s
alpha coefficients for the subscales were Assessment = 0.91, Practice/Intervention
Competency = 0.90, Resource Adequacy = 0.78, and Psychotropic Recommendation =
0.78. Given that two subscales had four or fewer items, these alpha coefficient estimates
showed adequate internal consistency for a newly developed instrument (Polit & Beck,
2008; Rutledge et al., 2012, p. 2762).
61
Modified Behavioral Health Care
Competency
The BHCC did not include items related to conducting mental status examinations
or knowledge of psychotropic medications. Rutledge et al. (2012) recommended items in
these areas might be added to a future version of the BHCC. Learning to conduct a
mental status exam and understanding common and serious side effects of the major
classes of psychotropic medications have been major foci of the mental health curricula
and clinical practica in nursing education. Therefore, minor item modifications were
made to the BHCC for this study to adapt it for the research population of nursing
students. A comparison of the 23-item scale with the adapted version appears in
Appendix G.
The modified survey (Tice, 2018) is a 22-item scale with three subscales:
Assessment (10 items), Practice/Intervention Competency (nine items), and Resource
Adequacy (four items; see Appendix G). To include mental status exams in the survey,
item one on the original scale was reworded from “I can assess patients for potential
mental health conditions” to “I can assess patients for potential mental health conditions
using a mental status exam.” The original subscale of Recommendation of
Psychotropics, which consisted of two items, was removed because the recommendation
of psychotropic medications to physicians was deemed to be beyond the scope of nursing
practice and would not be a valid item for student nurses. The items from that subscale
were condensed and re-worded as “I know appropriate psychotropic drugs to request
physicians to order for increasingly anxious or agitated patients.” The item was placed
within the subscale of Practice/Intervention Competency.
62
The modified BHCC was used with a similar sample of baccalaureate nursing
students in a pilot study in spring of 2018 (Tice, 2018). To evaluate the reliability and
validity of the modified BHCC when used with a sample of student nurses versus
experienced hospital nurses, Cronbach’s alpha was analyzed for each subscale and the
total scale score. To analyze if there were significant differences in the BHCC scores as
a result of prior mental health experience or English as a learned language, one-way
ANOVAs were conducted using these variables as factors and the BHCC total score as
the dependent variable. There were no significant differences.
Use of the BHCC survey in the 2018 pilot study resulted in a lower Cronbach’s
alpha for the subscale Assessment (original scale = 0.91; modified = 0.74) but a similar
Cronbach’s alpha for Practice/Intervention Competency (original scale = 0.90; modified
scale = 0.84) and increased Cronbach’s alpha for Resource Adequacy (original scale =
0.78; modified scale = 0.91; Tice, 2018). The Psychotropic Competency subscale in the
original scale had a Cronbach’s alpha of 0.78, which was attributed to be related to the
lack of nurse knowledge and experiential deficits (Rutledge et al., 2012). All subscale
scores showed adequate reliability estimates given a baseline Cronbach’s alpha > 0.70 for
all subscales and excellent reliability for two subscales with alpha of 0.84 and 0.91
(Remler & Van Ryzin, 2015). In this study, the Cronbach’s alphas for all subscales and
the total scale were excellent with alpha values of 0.89 or above (see Table 3).
63
Table 3
Scale Reliability and Descriptive Statistics for Study Variables
Clinical Learning Environment
Inventory-Actual
The Clinical Learning Environment Inventory-Actual (CLEI-A) is a 42-item scale
survey with six subscales: Personalization (seven items), Student Involvement (seven
items), Task Orientation (seven items), Innovation (seven items), Individualization (seven
items), and Satisfaction (seven items; Chan, 2002). The subscales of Personalization
(opportunities during clinical for interaction with caring and involved instructors or
preceptors), Involvement (the degree to which students are actively involved in clinical
activities), Innovation (the degree to which new learning activities and teaching strategies
are tried in clinical education), Individualization (the degree to which students are
allowed to make decisions and treated differently dependent on their abilities), and Task
Orientation (the extent to which activities are clear and well planned) appeared to be
Engagement Clinical Learning
Environment
Competency (BHCC)
MH LTC MH LTC MH LTC
M 65.6 56.8 83.3 79.9 87.5 90
SD 9.9 14.6 10.2 11.9 14.8 10.7
Range 32 46 35 39 62 41
Minimum 49 33 69 58 48 68
Maximum 81 79 104 97 110 109
Cronbach’s
alpha
0.93 0.88 .94 .96
Pre-BHCC Post-BHCC
Assessment 0.90
Interventions 0.89
Resources 0.91
Note. MH = Mental Health. LTC = Long Term Care
For Engagement, the minimum score is 17, the maximum score is 85.
For Clinical Learning Environment (CLE), minimum score is 22, maximum is 110.
For BHCC, the minimum score is 22, maximum score is 110.
64
good measures of the proximal processes as well as the CLE, which is why the CLEI-A
(Chan, 2002) was chosen for this study. Satisfaction measures overall student enjoyment
of the CLE (see Appendix D).
According to Chan (2002),
a response to each item in the CLEI-A is marked on a 4-point, Likert-type
scale, ranging between the alternatives of strongly agree, agree, disagree,
and strongly disagree. The instrument can be readily scored by hand.
Underlining an item number and writing the letter "R" in the researcher
use only column identified items that were reverse scored. Items not
underlined or without the letter "R" were scored by indicating the
corresponding number (i.e., 5 = strongly agree, 4 = agree, 2 = disagree,1 =
strongly disagree). The scoring direction was reversed for approximately
half of the items. Omitted or invalidly answered items were scored as 3.
(p. 73)
The CLEI-A was developed as a survey instrument by Chan (2002) based on
theories of classroom learning environments, literature review of classroom and CLEs,
expert opinion of classroom and clinical education nurses, and interviews with student
nurses. Chan modified an existing measurement tool, the College and University
Classroom Environment Inventory, which was designed to measure higher education
classroom learning environments. Although there are two versions of the CLEI (the
CLEI-Preferred and CLEI-Actual), the CLEI-A, which was designed to measure how
students perceived the actual CLE, was used in this study (see Appendix D).
65
In initial validation studies conducted with a sample size of 108 pre-registration
nursing students, values obtained for Cronbach’s alpha coefficient for the CLEI-A form
ranged between 0.73 and 0.84 and for the preferred form from 0.66 to 0.80 (Chan, 2003).
These reliabilities suggested each CLEI-A scale had adequate internal consistency for
subscales containing seven items each in both the actual and preferred forms (Chan,
2003, p. 526). To calculate discriminant validity for the actual version, the value
obtained for the mean correlation of a scale with other scales ranged between 0.39 and
0.45. For the preferred version, the correlations ranged from 0.23 to 0.42. These
findings indicated the CLEI-A measured distinct, although somewhat overlapping,
aspects of the hospital learning environment (Chan, 2003, p. 526).
Measuring Aspects of Engagement
and Quality of Clinical Learning
Environment
To measure engagement, the CLEI-A subscales of Student Involvement,
Satisfaction (Chan, 2002), and four researcher-developed Likert scale items were
combined to form a 22-item Likert scale. Six items were removed that had weak inter-
item correlation with the total scale (r < .2). Four items were added to measure
engagement: “During this clinical, I participated actively in all the learning activities”; “I
feel excited and curious to learn more while at this clinical”’ “During this clinical, I often
think about, reflect on, or ask questions about what I am experiencing”; and “Rather than
seeking out learning activities, I wait for the clinical instructor or staff to guide me”
(reverse scored). These questions were developed based on Reeve and Tseng’s (2011)
identification of the four aspects of engagement in student learning: (a) behavioral
engagement characterized by students being actively involved in their learning, (b)
66
emotional engagement characterized by student possession of emotions that facilitate
learning tasks, (c) cognitive engagement where students use sophisticated learning
strategies, and (d) agentic engagement where students actively seek learning
opportunities rather than passively receiving them (Wang et al., 2018). This focus on
learner dispositions, resources, and demands is a key construct in the PPCT model
(Bronfenbrenner & Morris, 2006).
The remaining CLEI-A subscales measuring Personalization, Task Orientation,
Individualization, and Innovation were used to index the perceived quality of the CLE.
By separating subscales of the CLEI-A that were within the student’s control and calling
those aspects “engagement” from environmental factors over which the student did not
have control (and calling those factors the clinical learning environment), person-
environment interactions and their relationship to competency development could be
studied (see Table 4).
67
Table 4
Scales to Measure Student Engagement and Clinical Learning Environment
CLEI-A (Chan, 2002) Original CLEI-A Tice Study
Clinical Learning Environment (22 items) Cronbach’s alpha=.88
Personalization 7 items (1,7,13,19,21,15,37) 7 items (1,7,13,19,21,15,37)
Task orientation 7 items (4,10,16,22,28,34,40) 5 items (4,22,28,34,40)
Innovation 7 items (5,11,17,23,29,35,41) 6 items (5,11,17,23,35,41)
Individualization 7 items (6,12,18,24,30,36,42) 4 items (18,30,36,42)
Engagement (17 items) Cronbach’s alpha = .93
Student
involvement
7 items (2,8,14,20,26,32,38) 6 items (2,8,14,20,32,38)
Satisfaction 7 items (3,9,15,21,27,33,39) 7 items (3,9,15,21,27,33,39)
Engagement 4 items (43,44,45,46)
Data Analysis
Quantitative Data
After the data were scanned and cleaned, values from each participant’s BHCC
and CLEI-A were entered into SPSS (Version 23 [IBM Corporation, Armonk, NY]).
Descriptive statistics were used to describe the sample. Subscale, individual item, and
total scores were calculated for the surveys. Mean scores (with standard deviations) and
internal consistency coefficients (Cronbach’s alpha) were calculated. Discriminant
validity was checked by calculating the mean correlation of one scale with other scales.
Repeated measures ANOVA with Bonferroni post hoc tests were conducted to
identify pre and post clinical differences in scores of the BHCC between groups over
time. Alpha was set at 0.05. Frequencies were run to measure changes in interest in a
68
future career in mental health or geriatric nursing pre and post clinical within and across
groups. Multiple linear regression was used to calculate relationships between the
predictor variables of type of clinical setting (mental health-hospital, mental health-LTC),
student engagement (measured by four researcher-developed items and the subscales of
Student Involvement and Satisfaction from the CLEI-A), the clinical learning
environment (measured by Personalization, Individualization, Innovation, and Task
Orientation on the CLEI-A; Chan, 2002), prior student experience in mental health or
LTC, English as a first or second language, future career preferences, and the criterion
variable of total score on the BHCC.
Qualitative Data
Audio-taped interview sessions were transcribed using Trint transcription
software. All personally and contextually identifying information was deleted before
entry into NVivo 12. The RA assigned numeric codes linking the data to quantitative
measures and replaced participants' names. Semi-structured interview data were coded
and thematically analyzed by the researcher. The themes were shared with the research
assistant and discussed. The researcher determined the themes used in the study. The
theoretical framework with the constructs of processes, persons, contexts, and time
served as the organizing template (Bronfenbrenner & Morris, 2006). Member checking
was done to validate the analysis.
Ethical Considerations
There were no foreseen risks to participation in this study other than the minor
inconvenience of the time and effort for self-evaluation taken to complete the surveys and
participate in the focus group. The BHCC (Rutledge et al., 2012) and CLEI-A (Chan,
69
2002) surveys took about 5-15 minutes to complete. The surveys were posted in the
online class learning platform where students could access them at a convenient time.
The research assistant de-identified the surveys before the researcher entered them in
SPSS (Version 23 [IBM Corporation, Armonk, NY]). The survey scores were not used
to grade the students. Potential benefits to the student included an improved awareness
of personal strengths and areas where more development was needed for PMH
competencies. A benefit to the nursing program and the profession of nursing was the
potential to gain information to improve mental health nursing clinical education.
Conclusion
This chapter explained the research methodology for the study including the
rationale for selection of a mixed methods case study design, sampling and setting, and
the process for obtaining informed consent. Ethical considerations pertaining to the use
of students as research participants were addressed. Data collection and handling for the
quantitative and qualitative strands and data analysis were also included.
Chapter IV presents the quantitative and qualitative findings of the study and
describes the comparative cases that emerged from the data. This discussion includes
how the data were merged and integrated and how the quantitative and qualitative data
supported or contradicted each other. The PPCT model (Bronfenbrenner & Morris,
2006) guided analysis and discussion of the results.
70
CHAPTER IV
FINDINGS
The primary purpose of this study was to compare and contrast how baccalaureate
student nurses’ level of engagement and the overall quality of the clinical learning
environment in inpatient mental health units and nursing homes were related to their (a)
perceived levels of PMH nursing care competency and (b) interest in a future career
working with the elderly and/or mentally ill. A mixed methods approach using case
studies and a sequential explanatory design for data analysis and interpretation was
chosen (Creswell & Poth, 2018). The analysis is organized by research questions.
Quantitative Results
Quantitative Research Questions
and Hypotheses
Q1 Is there a relationship between baccalaureate student nurses’ level of
engagement (IV) in mental health clinical education and the perceived
quality of the clinical learning environment (IV) with changes in their
PMH nursing competencies (DV)?
H01 The level of student engagement in mental health clinical and the quality
of the CLE are not associated with attainment of PMH nursing
competencies.
H1 The level of student engagement in mental health clinical and the quality
of the CLE are associated with attainment of PMH nursing competencies.
To answer the first research question, multiple linear regression was conducted.
The dependent variable was PMH nursing competency and the independent variables
were engagement level and the CLE. Results showed no significant correlations between
71
PMH competencies with student engagement or the perceived quality of the CLE.
Therefore, the null hypothesis was retained. However, a statistically significant, strong
correlation between the CLE and student engagement was found with a Pearson
correlation of .852 (p = .000; alpha set at 0.05).
As the level of student engagement and the CLE did not seem to influence
perceived competency, linear regression was performed to gauge the influence of the
following demographic variables on competency: prior work experience in health care
settings, English language learner, and level of interest in a future career in mental health
or in geriatric nursing. No significant correlations were found between competency and
the demographic variables. Small to moderate correlations were found between
engagement and interest in a mental health nursing career (r = .397, p =. 007), interest in
a geriatric nursing career (r = .298, p = .036), prior health care experience (r =.288, p =
.042), and English as a second language (r = .282, p = .045; see Table 5).
Q2 Does mental health clinical education in a nursing home or on inpatient
mental health unit (IVs) have a significant effect on nursing students’
attainment of PMH nursing competency, engagement and interest in a
future career in mental health or gerontological nursing?
Ho1 There are no significant differences between the two groups in PMH
nursing competency attainment, engagement, or interest in a future career
in mental health or gerontological nursing.
H1 There are significant differences between the two groups in PMH nursing
competency attainment, engagement, or interest in a future career in
mental health or gerontological nursing.
72
Table 5
Correlations Between Study Variables and Demographic Variables
To answer the second research question, repeated measures ANOVA,
independent samples t-tests, and frequencies for pre and post clinical changes in interest
in mental health or geriatric nursing were performed. Repeated measures ANOVA
showed a statistically significant difference related to an increase in scores on the BHCC
Total
BHCC
POST
Total CLE
(Context)
Engagement Interest
in MH
Career
Interest in
a Geriatric
nursing
career
First
Language
(English or
Other)
Prior HC
experience
Pearson
Correlation
BHCC
POST
1.000 .093 .054 -.110 -.168 -.201 .209
CLE
(Context)
.093 1.000 .852 .238 .282 .275 .163
Engage-
ment
.054 .852 1.000 .397 .298 .282 .288
Interest in
MH career
-.110 .238 .397 1.000 .451 .076 -.011
Interest in
geriatric
nursing
-.168 .282 .298 .451 1.000 .385 -.004
First
Language
-.201 .275 .282 .076 .385 1.000 -.057
Prior HC
experience
.209 .163 .288 -.011 -.004 -.057 1.000
Significance
(1-tailed)
BHCC
POST
. .292 .376 .258 .160 .117 .107
CLE
(Context)
.292 . .000 .078 .046 .050 .168
Engage-
ment
.376 .000 . .007 .036 .045 .042
Interest in
MH career
.258 .078 .007 . .003 .328 .474
Interest in
geriatric
nursing
.160 .046 .036 .003 . .009 .491
First
Language
.117 .050 .045 .328 .009 . .369
Prior HC
experience
.107 .168 .042 .474 .491 .369 .
73
tool for both groups over time. There were no statistically significant differences in
scores between groups.
Independent samples t-tests were conducted to test for differences between the
two groups in PMH competency attainment: the perceived quality of the clinical learning
environment and student engagement. Alpha was set at 0.05. Results found no
significant differences in BHCC scores between students who attended mental health
clinical in inpatient mental health versus in a long-term care setting (p = .556). Post-
clinical, students on mental health inpatient units for their mental health clinical had a
mean score of 87.5/110 on the BHCC (SD = 14.84) and students attending nursing homes
for mental health clinical had a mean score of 90/110 (SD = 10.74), indicating both
groups attained relatively high scores on their self-evaluated PMH competencies post
clinical.
There was a significant statistical difference between groups in student
engagement (p = .047), with students in inpatient mental health having a mean
engagement score of 65.5/85 (SD = 9.9) and students in nursing homes had a mean
engagement score of 56.8/85 (SD = 14.64). There were no significant differences
between groups in CLE scores (p = .367) with a mean CLE score being 83.3/110 (SD =
10.25) for students in mental health units and a mean CLE score of 79.9 (SD = 11.9) in
the nursing home setting. To determine if significant differences between groups existed
in any of the subscale variables for the CLE, independent samples t-tests were conducted
to compare the groups on each subscale variable. Results confirmed there were no
statistically significant differences between the groups on any of the subscales except for
74
Satisfaction (p = .018), which was used with the subscale of Student Involvement from
the CLEI-A (Chan, 2002) and four researcher-created items to measure engagement.
Across cases, an increased number of students expressed interest in a future career
in mental health or geriatric nursing post clinical. Prior to MH clinical, seven students
reported being interested in MH nursing and two students were interested in geriatric
nursing. Post mental health clinical, a total of 9/37 (24%) nursing students expressed
they agreed or strongly agreed they were interested in a future career in mental health
nursing and 5/37 (13.5%) agreed they were interested in a future career in geriatric
nursing.
Summary
Results of linear regression showed no correlation between engagement and
competency. A strong correlation was found between engagement and CLE. No
significant correlations were found between competency and the demographic variables.
Small to moderate correlations were found between engagement and interest in a mental
health nursing career (r = .397, p =. 007), interest in a geriatric nursing career (r = .298, p
= .036), prior healthcare experience (r=.288, p = .042), and English as a second language
(r = .282, p = .045).
No statistically significant differences were found between the groups in
perceived attainment of PMH nursing competency. Students in both groups were able to
attain moderately high levels of PMH nursing competency as measured by the BHCC
(Rutledge et al., 2012). Students who reported that English was not their first language
expressed a significantly significant interest in a future career in geriatric nursing pre and
post clinical than students who reported their first language as English.
75
Qualitative Research Question
The research question for the qualitative strand of the study was as follows:
Q3 What is the student nurse experience of attending PMH clinical education
in nursing homes versus inpatient mental health units?
Case Context and Description
Consistent with a case study design, cases were also set up in NVivo 12. The
cases were organized as (a) four junior-level students and one senior-level student
attending MH clinical on inpatient MH units at the same hospital and (b) four junior-level
and two senior-level students attending MH clinical in the same nursing home for
veterans. Senior-level students were included both in the study as a means to validate
themes emerging from the current students and to see if student perspectives of their
experience changed over time.
Data Analysis and Representation
Student interviews with junior and seniors (n = 11) and participant observations
and field notes stemming from the researcher’s roles as clinical instructor and theory
instructor were sources for the qualitative study. A constant comparative method was
used for analysis and interpretation including searching for word repetitions, key words
in context, metaphors and analogies, missing information, and looking for relationships
between themes (Ryan & Bernard, 2003). Creswell and Poth’s (2018) template for
coding a case study (using a multiple or collective case approach) was used to organize
and report the data in this section (p. 172).
The following initial codes for theme analysis were derived from the semi-
structured interview questions and Bronfenbrenner and Morris’ (2006) PPCT model: (a)
processes (defined as examples of student interactions with other people, objects, ideas,
76
and activities in their clinical learning environment), (b) characteristics of students that
impacted learning, (c) experience, (d) time factors, and (e) attaining competency.
Interview data were searched for examples related to the codes and organized in
corresponding nodes in NVivo 12. With results of the quantitative data in mind, using
the PPCT model (Bronfenbrenner & Morris, 2006) as the lens, the qualitative data were
analyzed and organized with an attempt to both bracket the researcher’s assumptions as a
participant observer while also being alert for rich data that could help explain
discrepancies in the quantitative data.
Within Case Theme Analysis
To develop an in-depth portrait of a case, the first step was to look at each group
as a separate entity and develop the themes in each case (Creswell & Poth, 2018). Within
case themes for Case One, student experience in inpatient mental health is explained first,
followed by Case Two, student experience in a nursing home for veterans. For each case,
an overarching theme, representative of the overall experience of being a student in the
environment is presented. Next, themes related to variables affecting student
satisfaction/engagement with the clinical experience is identified, followed by variables
affecting dissatisfaction/disengagement. Table 6 provides a summary of the major themes
within cases.
77
Case One: Common Themes in Inpatient
Mental Health Setting
Overarching Theme: An Eye Opener
This theme came directly from one of the participant’s responses to the initial
interview question of “Tell me about your experience in mental health clinical on an
inpatient hospital unit? What was it like?” She responded, “It was an eye opener for me.
Being the first time going into a mental health facility to experience and interact with the
people personally one on one. It was a good beginning, which is that we were wanting.
(MH 9). Another student continued the theme of open eyes by contributing how the
experience provided a new perspective: “Being at clinical in inpatient mental health gave
me a different perspective of what mental health nursing can look like. I actually had an
interest in mental health nursing, and I potentially might go into it in the future” (MH 7).
Another eye-opening experience was attending interprofessional team meetings
between the psychiatrist, social worker, charge nurse, OT, and nurse manager that met
daily to discuss patients and treatment planning: “Attending the team meeting helped me
understand teamwork. Because if you tell me something from your perspective and what
you see. And I've also given you mine, then we all put the information together and are
able to deal with it” (MH 9).
Theme Two: An Unexpected Pleasure
This theme was representative of unexpected sources of student satisfaction and
engagement in the inpatient mental health clinical setting. The mental health staff nurses,
clinical instructor, and patients provided a sense of camaraderie, emotional safety, and
connection that students had not expected to find on a mental health unit:
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Those nurses were actually the best group of nurses that I've worked with during
any kind of clinical. The nurses on all the floors were all super nice and
supportive. They would always answer our questions. They weren't very
standoffish, which I know some nurses in different hospitals can come off that
way. I also have acute care clinical. And those nurses were just a lot different
than the ones in mental health just because they were so busy running around.
They [Acute care nurses} rarely take the time to talk to us, get to know us, or tell
us about themselves and their experiences. So they [MH nurses] were definitely
the best people to work with and they were very helpful during that time. And
also my clinical instructor, she would always come visit us and talk to us for a
while. So, great support. (MH 7)
The way I see the nurses there, I mean, they're all good, but the mental health
nurses they are different. Like some inner religion or soul that is guiding them,
their approaches. These people [patients] will say something awful to them and
they will understand. "OK, I'll be back. I'll do this." And it never controls them
there's no competition. They are relaxed. (MH 9)
So the nurses, how they interacted with each other, they were very comfortable
and they helped each other out as much as they could, which is nice. Some
different units, whether it's mental health or not I [don’t] think all nurses actually
help each other. Compared to like other med surg units and all. I feel like they're
more connected as a group and more supportive. (MH 7)
Theme Three: Restricted Access
This theme was representative of sources of student dissatisfaction and
disengagement in the inpatient mental health clinical setting. The following student
statement was representative of this theme:
Student: There wasn't really too much going on that we could do. We were also
told to stay behind the nurse's desk. A lot of time just in case something was
happening. Again they were looking out for our safety. I'm a student, so I get
that.
RA: Did you feel like that hindered your participation in any kind of learning
activity at all? Being told to stay back?
Student: I think it did, because it kind of did put fear in the back of my mind.
Like they're gonna get mad at me if I'm walking around or something's going to
happen if I walk around. Which I didn't think would even happen anyway if I
were to be walking around on my own. But I just didn't want to risk getting in
trouble or having them say, “oh you need to be staying behind the desk because
we don't want anything happening to you.” I just wanted to avoid conflict. If we
were told to go out and explore more or talk to the patients, you know, even if
that's not the patient we were focusing on that clinical. I feel like I would have
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done more. But since the very first day, they're like,” oh, you need to stay behind
the desk” that’s kind of what I did all four weeks. (MH 7)
Two other students explained:
There isn't as much to do. Because you can't do a lot, I don't think. I don’t
remember if we were allowed to give meds or not, but we couldn't bring our
stethoscope or have like our name tag with a badge reel because it's a safety
hazard to have that string and something they could use. It was just a lot
different. There was a lot more sitting and talking versus actual nursing
assessments and things. (MH 8)
The only thing that I didn’t like was that at [Hospital Name] we weren't allowed
to do like a lot of things like passing out meds or like being one on one with
patients. But other than that, it was like super great and I loved it. I learned a lot.
The nurses were super nice. (Senior nursing student MH 11)
Finally, student emotions could restrict students’ engagement and learning in the
CLE:
The only thing that stopped me was my own emotions. You know to see young
people being in this situation, being abused. They cannot lead a normal life. So, I
try to fight for my emotions so they don't get in the way because it was my first
time actually being environment seeing the life of the people on the other side -
different from your life. And trying to imagine what they are going through was
tough for me. But then my clinical professor told me that this is safe. This is a
safe place for them. (MH 9)
Case Two: Common Themes in a Nursing Home Setting
The overarching theme for the environment and themes was associated with
sources of satisfaction and dissatisfaction for Case Two.
Overarching Theme: The Great Divide
Reading through student transcripts of qualitative data was a puzzling experience
for this researcher and her research assistant. We found ourselves asking each other
whether these students were in the same clinical learning environment and wondering
how their perceptions could be so different. These feelings of confusion aligned with the
contradictory results of the quantitative data, which indicated that even though students in
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clinical at the nursing home rated the clinical learning environment as a good one, rated
their post-clinical competency on par with the other group, and students reported they
gained or retained interest for a future career in mental health or gerontology, they had
significantly lower levels of satisfaction and engagement with the clinical experience.
These contradictory reports also aligned with the researcher’s own experiences and
feelings of frustration as a clinical instructor; she could see with her own eyes that about
half the students were engaged and half were not. The overarching theme for the student
experience of attending mental health clinical at a nursing home was identified as “the
great divide.” Student comments representative of this theme are shared.
The positive side of the divide: New nursing perspectives. These student
quotes reflected the positive learning experiences of students attending mental health
clinical at a nursing home. The statements also captured the variety of meaningful
learning experiences and interactions with people, objects, and ideas that engaged them in
processes contributing to competency development. The themes of new perspectives and
seeing things differently identified by the students in inpatient mental health were also
evident in the experiences of students in LTC.
I really enjoyed the clinical. I had the opportunity to practice therapeutic
communication and learn more about different mental health conditions, which I
wasn't really aware of before. And just like interacting with a patient to see how
each of them behaves differently. Yeah. This was the first clinical that I felt like
a nurse. Compared to my acute care clinical and my community health, I felt like
a nurse at mental health (clinical at a nursing home). (LTC 3)
I feel like when most people think of a nursing home or assisted living, they think
oh, these people just need a little help with daily living. But [in mental health
clinical in LTC], we're going to complete the mental health exam. You're going
to observe. You're going to notice. Look at their charts. Look at their
medication. And are they having side effects, like learning the side effects of
different medication. Coming from that perspective is what I enjoyed. I work at
a nursing home. But when I worked [as a CNA], I didn't see it that way. But
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when we went to clinical, I see it in a different way of care for the residents. So
that's what I liked. It's like you see it differently, like a different perspective.
(LTC 2)
The negative side of the divide: Feeling robbed.
It's frustrating hearing all the girls come back from Name of Hospital and hearing
about all these mental health conditions that they got to experience and deal with,
see, and ask questions about it. I didn't get any of that and I felt like that
experience kind of robbed from me almost. You know, I'm paying for my
education and that's the kind of experience I want. So sure, sounds selfish, but
that's what it is. (LTC 1)
Honest to goodness, I was super excited to be placed with the nursing home
initially. And then [a peer], she flat out told me that that place sucked and kind of
put me in a bad mood about it. And I let that dictate a lot of my emotions toward
clinical and the negativity that surrounded it. And I know this is something that
you and I had talked about back when I was in clinical and I have definitely felt
really bad about that because I really wish that I wouldn't have let other people
dictate my feelings about being excited about something. (Senior LTC 6)
Theme Two: Feeling at Home
This theme was representative of sources of student satisfaction and engagement
in the clinical setting.
At mental health clinical, I felt more comfortable talking to patients. It's like last
semester at acute care I was very uncomfortable talking o patients and I made sure
to let my clinical instructor know that. I did not feel like a nurse because I just
did my head to toe and passed meds (when we're able to) but I really did not feel
like I was doing much in acute care as compared to mental health. When I'm
nervous, I completely shut down so that also like played a factor in it too. But in
mental health I felt very comfortable. The residents there are very welcoming and
they appreciated me talking to them more than anything else. (LTC 3)
I learned a lot from the nurses that I was paired with just because of the amount of
time that they spend with their patients. They got to know them super well. And
they were able to relay that knowledge to me about patients. So I just I found that
I learned a lot about how to be a nurse in that sort of setting and how to care for a
patient who is vulnerable in that setting. (Senior LTC 5)
The CNAs that I worked with were really, really nice and it was a nice clean
environment. I liked the nursing home. Yeah, I think everything was really
supportive there. (LTC 1)
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Theme Three: Feeling “Less Than”
In the first semester of the nursing program, students received this message from a
nursing faculty:
We were kind of told sophomore year, like, hey, you only have two weeks long
term care and then it's all hospitals from here on out. And so when people got
placed a long-term care facility for an entire semester [in their Junior year], I
think that's where people kind of freaked out of it. And they were like, what the
heck? And then at the same time, it was very rare to see a PIC line or an IV. Oh,
I mean, there were a couple catheters, I think, but like it was very rare to see these
more acute issues that we would have seen [at a hospital.] (Senior student LTC 6)
Other sources of dissatisfaction came from students assigned to the VA hospital for acute
care and an LTC for veterans for mental health clinical. Some students with previous
work experience as a CNA also expressed role confusion in the nursing home and
questioned whether they could learn the nurse role in LTC:
I was at the nursing home [for mental health clinical]. I have a V.A. hospital for
my acute care clinical, too. And so we were there for four weeks. I had a good
clinical instructor. But I don’t think that mattered much because of the location.
(LTC 1)
And so we basically were like, in my opinion, like CNAs because we
would get assigned a patient and then they us to go with our CNA [to meet our
patient]. Which makes sense. But we're at a nursing clinical. We've done a
rotation at a nursing home before last year in our sophomore year. So it was kind
of just felt like it was repeating itself. (LTC 1)
A lot of the nurses that I felt like we got to follow in the hospital setting were very
much interested in enriching students and asking them challenging questions and
really wanting to help them learn and grow. Whereas in the nursing home, we
had one nurse, just three of us roughly at a time. And a lot of times they were
really overwhelmed because they had all of those patients to do treatments for.
And the last thing that they really needed were three student nurses that are all
doe eyed like, what do you want? And a lot of times I felt like the staff, like the
CNA. We were we were preparing the patients, which honestly was great for the
head to toe to be able to work with them, to get them dressed and stuff, but other
people [students] were really frustrated. Like, I already know what it's like to be a
CNA. (Senior LTC 6)
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Contradictory and invalidating messages were part of the students’ experiences in
LTC beginning in the first semester in the program and continuing into their junior year.
Confusing messages came from many people: students, staff, and faculty. Mismatches
occurred not only in what they said but in their actions and the level of agreement or
disagreement in how they viewed situations and set up learning activities. These
experiences contributed to student ambivalence. Similar to sources of dissatisfaction for
students in MH, students in LTC also reported feelings of being restricted but to a much
lesser degree:
Student: So we went to the nursing home for four weeks. And it was it was OK.
I feel like we got to do a lot of things. You got to experience the mental health
side of it. The experience was really disorganized and there wasn't a lot to do.
RA: Can you elaborate on what you felt like was disorganized?
Student: They'd put you on the floor and you kind of have a plan [based on
assignments your clinical instructor gave you] and then the nurse [manager]
would be like, well "no" you can't do that. You can't do that. And then they
would change it [and say], “Well, now these are your patients.” You'd interview
your patients and you'd be done in like an hour. And then the rest of the day, you
don't have anything to do. (LTC 4)
[One of the RNs told us] “I'll be honest with you girls. This isn't a good place to
learn mental health.” And like, hearing that from a [former] mental health nurse
and from someone that works there [in LTC care now] is like, OK, we're not
crazy, we know. This isn't like the best learning experience for this rotation.
(LTC 1)
Another contribution to feeling “less than” occurred when students talked to each
other and compared notes on their experiences. Peers, especially those who were
roommates or close friends, could have a significant impact on student attitudes and
perceptions of their clinical experience. As students talked among themselves, rumors
arose. Some students in LTC for mental health confided they thought they had been
purposely placed in that clinical because they were considered the lowest students in the
class:
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If I'm being honest, it's not fair. When people get to go to inpatient mental health
and others don’t get to do that. But every single person, I guarantee you, a
hundred percent of the class would rather have had time least at (Name of
inpatient mental health hospital). (LTC 1)
Coming home from clinical every week. And she'd be like, oh, I don't want to
hear what you did because it's not as cool as what I did today. Looking back at it
now I totally regret not picking myself up more and believing in the fact that there
is a reason and there's a purpose that I was placed at this location. It's a random
thing. It's not something that you guys purposefully plan out at all. It's a random
assignment. And that's a lot of self development that I feel like I've done over the
course of time. (Senior LTC 6)
Cross Case Themes
After the within case themes were identified, cross case themes were explored to
identify themes that were similar and different. Table 6 provides a visual organizer of the
similarities and differences across cases. First, two themes highlighting similarities are
discussed. Overall, there were many similar themes across cases. The themes of seeing
new perspectives, making connections, receiving messages or being told, the influence of
peers, time factors, and personal characteristics, especially emotions and attitudes of
being open or closed came up frequently across cases.
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Table 6
Within and Across Case Themes
Inpatient Mental Health Shared Themes Nursing Home for Veterans
Overarching Theme
An Eye Opener: Being on a an inpatient mental health unit allows
students to see what mental health
units are really like and provides students new perspectives about
mental illness.
Related to Competency
Connecting the Dots
• Competency development is a process
which occurs over time and grows
with experience, repetition, support, role modeling and feedback.
• Students in both settings agreed that
they felt ready and mostly confident to
provide PMH nursing care. This was
consistent with the quantitative data.
Being Open: Developing PMH
competency requires being open-minded, compassionate, patient, non-judgmental,
skilled in answering sensitive questions,
and confident.
Overarching Theme
The Great Divide: Although students were attending clinical on similar units with the
same clinical instructor, their perceptions
of the experience were very different. About half viewed the experience very
positively, and the other half, had a very
negative view.
Common Theme Related to Student
Satisfaction and Engagement
An Unexpected Pleasure:
• The clinical instructor as a safe
anchor and source of support
• The patients as authentic
storytellers that teach about
different mental illnesses.
• The nurses ask us how we are
doing and laugh and joke with
us.
• Surprisingly, an emotionally
safe place for learning.
Related to Opportunities for Meaningful
Learning and Time Factors
Wanting More:
• Opportunities for learning – lifting
restrictions
• Active versus passive learning:
• Doing more, watching and listening
less
• The power of questions and being
asked versus being told
• Variety in mental health clinical
experiences
• Greater understanding of
psychotropic medications and being
able to administer, learn to monitor and provide patient teaching.
• More time to learn PMH
competencies.
Common Theme Related to Student
Satisfaction and Engagement
Feeling at Home
• The clinical instructor as a
knowledgeable interpreter to connect
experiences to mental health and as an advocate to open access to
learning experiences
• The residents are warm, engaging,
patient, enjoy interaction, have great
stories to share. “I learned the most from them”
• Peers as a “double-check”, source of
support, and feedback
• The home-like and friendly
environment
• A resource-rich environment
Common Theme Related to Student
Dissatisfaction and Disengagement:
Restricted Access
• Related to environment, patient
acuity (acute mental health symptoms)
• Fighting against my own
emotions
• The staff wouldn’t let us do
much due to safety
• I wasn’t allowed to give
medications or do assessments.
Common Theme Related to Student
Dissatisfaction and Disengagement:
Feeling “less than”
• Frustration due to role confusion
• Unknowing and ambivalence due to
conflicting messages from many
people and sources
• Making comparisons and feeling
disadvantaged
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Connecting the Dots
Students in both settings shared many examples of how they learned to “connect
the dots” and gained new perspectives and greater confidence and competence in their
PMH knowledge and skills.
It was interesting to see and to compare my perceptions of what mental health
nursing was like before [and after]. So I thought that was pretty cool, like to see
what it's actually like on a mental health floor. (MH 8)
So I think my favorite part was just like helping her (my clinical instructor) or her
helping me kind of connect the dots and she would talk through the mental status
exam with me with the patients I had, and that was helpful. So I would say just
like the collaboration with her was my favorite part. (LTC 6)
When you sit in one of those [interdisciplinary team care conference] meetings,
you realize, oh, everyone is contributing to that individual to give them better
care. I remember the behavioral analyst, she was explaining how she was
observing showers and daily cares, and how she noticed that patients had more
anxiety and got more agitated if they weren't covered up after taking a shower and
just being mindful of that. So seeing that perspective of how the behavioral
analysts contribute to the residents’ care was interesting because like the nurses
and the people doing the daily cares were like, “Oh right. Of course, we should
cover them right away. The different perspective from that professional helped
us. (LTC 2)
[The care conference I attended] was the end of life conversation, even though he
was doing well, he wanted to switch his status from full code to DNR, DNI and
his family was like, you can't do that. And he's like, yes, I can. I’m fully
competent. I don’t want all the CPR and all the lifesaving measures you would. I
don't want that anymore. I'm old. (LTC 6)
I think I've learned the most from my interaction with patients. Talking with the
patients, getting to know the patients was what helped me understand mental
health, like how to implement, you know, the exams, like the mental health status
exams and understanding how to interact with people who have like certain
mental illnesses. (LTC 2)
I learned a lot about people's baseline because there was like a woman and she
was pacing up and down hallways like talking to herself. It was kind of like odd
behavior for me. But she was being discharged and I was like, well, how can they
discharge her like that when she's obviously still having these hallucinations?
[And they explained] well, that's her baseline and that's where she is normally.
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She's safe. She's not hurting anybody. She's not hurting herself. So it's like,
wow. Yeah. People's baselines are really different. (MH 10)
It was really helpful to have mental health content [in class] and I wish if
you did like a mental health orientation [in clinical] where we could go over like
an example of what a mental status exam looks like or how to interview a patient
instead of just trying to figure it out as you go. But the fact that they let us do it in
pairs was really helpful. It was just on that first day when we couldn't do it in
pairs that was not helpful. Yeah. Having someone to do it with you definitely
helps. (LTC 4)
While the above examples of competency development were inspiring, a more
negative connecting of the dots seemed to be happening to students through distorted,
probably unintentional, messages the students were receiving that (a) in inpatient mental
health, they were not safe to interact with the patients independently and should be
fearful of people with mental illnesses; and (b) in LTC, the work in a nursing home is not
as valuable or exciting as that in inpatient mental health. Both groups of students
complained of “sitting around having nothing to do.” As much as they complained about
the frenzied pace of their acute care clinical experiences, their attitudes suggested they
viewed that pace and a task orientation as more valuable and expected of a “real” nurse
than “sitting and talking.”
Being Open
Students were asked about personal characteristics they thought would facilitate
or hinder their ability to develop PMH competency. Eight of the 11 students interviewed
mentioned the idea of being open in some form (open, open-minded, empathetic,
accepting, non-judgmental), or talked about not being closed (thinking you know it all,
not listening, being judgmental) as a barrier.
If you're close minded to experience, because I know not everybody was fond of
the idea of going to mental health clinic [at LTC]. If you go there thinking I
won’t enjoy this clinical or I don't care for these people. Then you won't gain
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anything from the experience whatsoever. And so just making sure you're open
minded, you're open to the experience, you're open to the patients. You're just
very approachable. (LTC 3)
Researcher: Did you have any fears or concerns before you came to [clinical in
LTC 3]?
Student: Yes, but most of my concerns were biases that I have. Yeah, it was
really it was more like stigma that hurt, like learned throughout my life. For
example, I have a feeling, oh, we're going to a mental health, long term care
clinical, what if the patients are violent. What is this? So just like all the biases
we've talked about in class, I had some of those just going into clinical and these
were really some of the nicest people I've ever seen. It was really nice to have
those, like, biases. What's the word? Not having those biases anymore. (LTC 3)
Having too much fear kind of prevents you from learning more about the patient
and interacting with them. It’s OK to interact with them and knowing the right
things to say. And when you have too much fear you are never going to take that
step forward. You're never going to understand that they’re going through or
understand their illness. You're just gonna have that fear in the back of your mind
and you won't ever want to deal with anybody, whether it's on the unit or out in
the real world. (MH 7)
Other characteristics mentioned often were confidence and being prepared.
RA: What personal characteristics do you think students need in order to be
successful in developing competency in mental health nursing?
Student: Definitely confidence in what you’re doing. Being prepared. I think
my first clinical I wasn't prepared to see the seclusion rooms. I didn't even know
that they still use those. I didn't know the reasons that any mental health unit had
that. So definitely being prepared for that. I don't remember hearing about it
much during class either that they still use that or how they how they put patients
in there. To me, it was just really sad. But then once I saw it myself and saw why
they use it, I was more understanding of it. It's definitely necessary sometimes.
(MH7)
Wanting More
Qualitative data indicated the majority of students highly valued their mental
health clinical experiences. Most of the students interviewed expressed wanting more
time in mental health clinical to acquire PMH competencies, especially psychotropic
medication management, and de-escalation skills.
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My sister is a nurse on a med-surg unit and she told me, ‘Make sure you learn
your mental health skills because so much of nursing is mental health’. I want to
make sure I learn this and am ready for practice [Field notes]. I loved my mental
health experience. I wish it was longer. I was dealing with a patient that
impacted me in so many ways. He was a psychiatric patient from [my same
culture]. And because we shared the same cultural aspect it was a really
meaningful experience. (Senior MH 11)
Community health was eight weeks where we spent four weeks at one site and
four weeks at another site. We could do a similar thing for mental health, where
everyone gets four weeks at long term care and four weeks at inpatient mental
health. Everybody gets both experiences, noting the similarities between inpatient
MH and the nursing home and the differences. (LTC 3)
I could have learned a lot more if we maybe had a little extra time [on the unit] or
a couple more weeks with mental health. If we were to have more experience
with passing meds, I think I would be a lot more confident. And also maybe
having equal [time] between acute care and mental health clinical. I think that’s
most important because we have 8 weeks of acute care [each semester] and only
four weeks of mental health. I feel like it should be balanced somehow I think it’s
important. (MH 7)
Well, like we get eight weeks [of clinical] for acute care clinical. And I think if
we got like eight in mental health, we could see a lot broader view of the kinds of
illnesses people go there with and how serious they are and how different people
deal with them. And that would make it more obvious that mental health is just
important as acute care nursing or dealing with medical problems. It's just as
important. (MH 10)
RA: So how can faculty improve clinical mental health education do you think?
Student: I think they need more. I think students need more mental health.
Learning I mean, lectures in general. You're going in to like you read about
[mental illnesses] in a textbook and you learn about it, but you'd never realize
how serious it is until you're actually on the unit. So, definitely trying to improve
the education by giving us more lectures and then also maybe having do a
simulation either in person or like through a course point [virtual simulations].
(Senior MH 11)
Students also wanted more “hands on,” meaning active versus passive learning in
mental health clinical. Students recognized the value of observation and role modeling in
clinical learning. Students appreciated when faculty and staff were flexible and open to
trying new innovations in clinical.
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One of the weeks we got to do flu shots, which was a good learning opportunity
for us. When I didn't even think I was doing something wrong, like when I was
putting the [safety] cap back on afterwards, I did that wrong and my clinical
instructor was correcting me. So, like, I definitely learned stuff there. (Student in
LTC)
I really like how we have four patients [assigned to two nursing students to care
for]. Moving forward, I hope that continues. Instead of having one patient for the
entire time, like it was nice to have four patients and rotate around and you feel
like a nurse who has like four to one. I really liked the patient load. (Student in
LTC 3)
In thematic analysis, questions, asking, and learning were high frequency words
overall. Students expressed both how much they liked being asked questions as well as
how important it was for their competency development to learn what questions to ask.
All the tools [we used in clinical] are really helpful, especially the mental status
exam showing how were supposed to look versus abnormal. So if we notice
abnormalities within the patient we're able to document that. We already have an
idea of what's quote unquote, normal. And for the depression skills, [using the
Geriatric Depression Scale as a guide to] knowing which questions to ask. Like
when it comes to depression, there's so many questions you can ask. So it's nice
to have specific questions to ask. (LTC 3)
I really liked my clinical instructor when it came to like our post clinical
conference. I felt like she always had good questions and it really made us think
about what we were doing during the day and why we did certain things versus
just kind of giving us all the answers, which I thought was really helpful. (MH 8).
I really liked how we did like interviews with you prior to doing it with the
residents because it was good to learn. Oh, that's a good way to word that
question. Oh yeah. Actually, keep it open ended. I shouldn’t just ask “yes or no”
questions. And then like going through interview. I really liked it when we took
time to go in depth. Like the questions. Like the like behavioral, cognitive.
Because then I would be like, oh yeah, I should ask that. Why didn't I think of it
that way? So that I really liked that was easier after briefing it made it easier for
me to do it, so I got to do it. (LTC 3)
Students expressed wanting more for patients who had mental illnesses and
disabilities or vulnerability. Their conversations often touched on ethical and
sociopolitical themes.
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I think part of it is it takes a lot of time to really get to know somebody and what's
going on inside of them. Like, I can look at you, I can look at a patient. It's not
apparent to me what's really going on inside of them. And in order to get to know
that, I need to spend a lot of time with that person and I have to develop a
therapeutic relationship or they're not going to trust me and they're not going to
really share how what's really going on inside. And so I see that as being a big
problem in our current health care systems in that we don't have time. Yeah, not
currently. Especially those in nurses, as you saw at the nursing home. I mean,
they're basically giving medications to like 17 people. Like, how could they
possibly have time to talk to them more? I don't know, you can't just magically
make more time for patients who are experiencing mental health crises. But it's
something that everyone, every nurse should be informed of and aware of that
time is essential. I don't see that people are misusing the time that they have. But
it's just a lack of time. That's definitely an issue. (Senior LTC 5)
Another student expressed,
People with developmental disabilities are already super overlooked and nobody
takes the time to talk with them. It's super sad. That population in general is
overlooked because they can't talk and advocate for themselves. It's frustrating in
the group home too because staff there aren't trained. Not like nursing school.
You go through all this to be a[health care] worker and in a group home you just
have to pass a background check. You can work in a group home and work with
the people or you can feed them and put him in front of a TV. There's a lot of
people that just do the bare minimum. (MH 10)
Mixed Methods Question
The mixed methods research question was as follows:
Q4 To what extent do the similarities and differences between the groups
identified by the quantitative data support or contradict the qualitative
data?
Convergence of the Qualitative
and Quantitative Data
Quantitative and qualitative data converged when the results of each data set were
similar. Convergent data analysis revealed no significant differences in perceived PMH
competency attainment between cases as measured by the BHCC tool pre and post
mental health clinical. All of the students received mental health theory in the classroom
over the course of the semester. The first group of students attending clinical in
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September 2019 had the least amount of theory before clinical (four weeks) and the
fourth group of students attending clinical in February to March 2020 had the most theory
before clinical practice (16 weeks). Across cases, students reported relatively high levels
of PMH competency as measured by the BHCC (Rutledge et al., 2012) post-clinical with
a mean gain of 18 points from baseline. In qualitative interviews, both groups of students
reported similar high levels of confidence and readiness for practice as being as three to
four points with five being “completely confident” and “completely” ready. Both groups
of students had experienced PMH clinical instructors and reported satisfaction with
clinical instruction and post conference debriefing as meaningful learning experiences.
Contradictory data were introduced by qualitative interview reports of half of the
students in the nursing home setting and many of the students in inpatient mental health
who reported “not being able to do much, mostly sitting and talking with the patients and
staff,” which could be a meaningful learning activity but student attitudes did not convey
that it was. Students in inpatient mental health reported being “restricted” and somewhat
fearful about venturing out on the unit. Qualitative data also suggests the students
received differing levels of time on the unit, access to meaningful learning activities,
exposure to interactions with staff nurses as role models, access to tools such as
computers, all factors the PPCT model (Bronfenbrenner & Morris, 2006) indicated would
impact competency development.
Divergence of the Qualitative
and Quantitative Data
Quantitative and qualitative data diverged when the results were dissimilar or
contradictory. One puzzling finding was while the both cases rated their clinical learning
environments as measured by four subscales of the CLEI-A (Chan, 2002) as relatively
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similar and no significant differences were found between groups for any the four
subscales individually, students in nursing homes scored significantly lower scores in
engagement and satisfaction than students in inpatient mental health. These quantitative
findings fit for three students interviewed but not for the other three. Qualitative findings
also indicated the students in inpatient mental health reported less time on the units, no
access to the electronic health record, and did few assessments; yet they rated their level
of engagement higher. Qualitative data revealed students attending mental health clinical
in a nursing home often experienced and expressed strong negative emotional responses
to being assigned to a nursing home as a site for mental health clinical, especially when
they compared their experiences to the other group and perceived their experience was
not as valuable.
Summary
In this chapter, findings from quantitative and qualitative analyses were described.
Areas of convergence and divergence between the quantitative and qualitative results
were merged to better understand complementary and contradictory findings between
data sets. In Chapter V, the results are interpreted and discussed and conclusions are
made.
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CHAPTER V
DISCUSSIONS AND CONCLUSIONS
The power of the proximal Processes to influence human development vary
substantially as a function of the characteristics of the developing Person, or the
immediate and more remote environmental Contexts, and the Time periods in
which the proximal processes take place. (PPCT model; Bronfenbrenner &
Morris, 2006, p. 795)
This chapter provides a summary of the study including background, purpose of
the study, and methodology. Results and interpretation of the results are discussed for
each research question and connected with findings of previous studies and areas for
further research. Finally, the limitations of the study are disclosed and the study is
concluded.
Background
A reality facing healthcare systems in the United States is the growing demand for
registered nurses who have skill sets to provide safe and effective nursing care to older
adults with chronic physical and mental health needs (Delaney, 2016; Husebø et al.,
2018; Skaalvik, 2011). The demand for nurses with expertise in geriatric nursing and/or
geropsychiatric nursing has far exceeded the supply (AAN, 2015). Ongoing workforce
shortages and stigmatized societal attitudes that devalued work with these populations
perpetuated cycles of rapid staff turnover and high vacancy rates due to stress and
burnout (AACN, 2019; Konnert et al., 2019). To break these negative cycles, nurse
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educators need to explore creative ways to identify, attract, recruit, and retain nursing
students to join the ranks of mental health, geriatric, and gero-psychiatric nursing.
Ensuring a sufficient workforce is one way to counteract workforce shortages
contributing to staff disengagement and attrition.
Engagement is a concept posited to be protective against stress and burnout
(Bernard, 2015; Bruce et al., 2010). Clinical learning environments (CLEs) provide
students with an authentic milieu for active learning, which should be engaging, but little
research has supported whether or not students are engaged in clinical learning and how
to measure it (Loch, 2013).
Purpose of the Study
This mixed methods case study was conducted to compare and contrast how two
groups of baccalaureate student nurses’ engagement with people, objects, and ideas in
CLEs shaped attainment of PMH nursing competencies and workplace attitudes. The
two groups of interest were (a) students attending mental health clinical on inpatient
mental health units, and (b) students attending mental health clinical in a nursing home.
Quantitative data were collected by surveys from junior-level students attending
mental health clinical in each setting to measure four variables: (a) students’ perceived
levels of engagement (as measured by subscales of the CLEI-A (Chan, 2002); (b) their
perception of the quality of the CLE post clinical (as measured by subscales of the CLEI-
A); (c) their perceived level of PMH nursing competency pre and post clinical (as
measured by the BHCC; Rutledge et al., 2012); and (d) level of interest in a future career
in mental health or geriatric nursing pre and post clinical (measured by two Likert
questions).
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Linear regression, repeated measures ANOVA, and independent samples t-tests
were used to analyze the quantitative data collected from 37 students. A case study
approach and thematic analyses were used to develop two in-depth cases using qualitative
interview data from 11 nursing students in the sample pool. Finally, quantitative and
qualitative data were integrated by analyzing and interpreting points where the data were
in agreement and points where they diverged.
Summary of the Results by Research Question
Research Question One
Is there a relationship between baccalaureate student nurses’ level of engagement
in mental health clinical education and the perceived quality of the clinical
learning environment with changes in their PMH nursing competencies?
There were no significant associations between student engagement or CLE and
PMH competency.
Research Question Two
Does mental health clinical education in a nursing home or on inpatient mental
health unit have a significant effect on nursing students’ attainment of PMH
nursing competency and interest in a future career in mental health or
gerontological nursing?
No statistically significant differences were found between the groups in
perceived attainment of mental health competency. Students in both groups were able to
attain moderately high levels of PMH nursing competency as measured by the BHCC
(Rutledge et al., 2012). Both groups made significant gains in competency over time
with a mean increase of 19 points after four weeks of clinical. Across cases, an increased
number of students expressed interest in a future career in mental health or geriatric
nursing post clinical. Prior to MH clinical, seven students reported being interested in
MH nursing and two students were interested in geriatric nursing. Post MH clinical, a
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total of 9/37 (24%) nursing students expressed they agreed or strongly agreed they were
interested in a future career in mental health nursing and 5/37 (13.5%) agreed they were
interested in a future career in geriatric nursing.
Research Question Three
What is the student nurse experience of attending PMH clinical education in
nursing homes versus inpatient mental health units?
Thematic analysis of the interview transcripts was used to develop in-depth
portraits both within and across cases. The themes of an eye opener, an unexpected
pleasure, and restricted access conveyed the portraits that emerged for students learning
on inpatient mental health units. For students learning within a nursing home, the themes
of the great divide, feeling at home or feeling robbed, and feeling “less than” were
identified. Themes common to both groups were connecting the dots (growth theme) and
wanting more (process theme).
Research Question Four
To what extent do the similarities and differences between the groups identified
by the quantitative data support or contradict the qualitative data?
The quantitative data suggested all students achieved moderately high levels of
PMH competency and had a relatively good quality CLE across settings. The number of
students who maintained or reported a new interest in MH nursing pre and post clinical
was in alignment with the engagement themes of an unexpected pleasure, feeling like a
nurse, feels like home, and the growth theme of connecting the dots.
Quantitative data results showed lower levels of satisfaction and engagement for
students attending clinical in nursing homes units. These findings aligned with
qualitative data for three of the students interviewed but not with three of the other
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students (the great divide theme). Students in inpatient mental health identified different
sources of dissatisfaction from students in nursing homes but overall, the inpatient mental
health students were more satisfied with and engaged in their experiences
Interpretation of the Findings
Research Question One
Is there a relationship between baccalaureate student nurses’ level of engagement
in mental health clinical education and the perceived quality of the clinical
learning environment with changes in their PMH nursing competencies?
Learners’ levels of engagement with the curriculum and the extent to which they
chose to interact with learning activities was well supported in the literature as being a
necessary prerequisite for learning and competency development (Newton et al., 2009;
Wang et al., 2018). Nursing students’ ability to transfer what they learned in university
classrooms and skills labs to clinical practice was dependent on personal, social, and
environmental factors with student engagement being a key factor (Hudson et al., 2019;
Newton et al., 2009). In this study, there were no significant associations between
student engagement or CLE and PMH competency. However, students who attended
MH clinical in a nursing home had significantly lower levels of engagement and
satisfaction than students on inpatient mental health hospital units; yet, both groups
attained similar perceived levels of moderately high PMH post clinical. Previous studies
suggested the less engaged students in nursing homes should have lower levels of
competency development than the more engaged students in inpatient mental health.
Two factors might have influenced these findings: (a) the scale designed to measure
engagement, and (b) the complexity of identifying how other factors besides engagement
contributed to competency development.
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Measuring engagement. The measurement scale used for engagement was
created by the researcher by using two existing subscales from the CLEI-A (Chan, 2002)
with four Likert items to measure four aspects of engagement based on conceptual
models of Reeve and Tseng (2011). This measurement scale might not have been an
accurate measure of student engagement. In addition, use of student self-evaluation with
Likert surveys could have been biased or inaccurate, although consistencies between the
quantitative and qualitative data and field observations supported validity of the students’
perceptions.
Measuring effects of other contextual factors. According to the PPCT model
(Bronfenbrenner & Morris, 2006), although the proximal processes were central to
development, the power of learner-environment interactions could vary substantially
dependent on the characteristics of the developing person, the immediate and more
remote environmental contexts, and time. These PPCT factors were all identified as
sources of engagement and disengagement and satisfaction and dissatisfaction across
groups. Although some of the students in the nursing home were significantly less
satisfied and engaged, other factors such as a good quality CLE, experienced PMH
clinical instructor, debriefing sessions, peer support, and/or mental theory class might
have offset negative effects. It was also possible the students learned as much from
learning activities they did not enjoy as from activities they did enjoy.
Effects of stigma as a remote contextual factor. In this study, stigma was a
contextual factor that significantly impacted student engagement across settings but
appeared to be more prevalent and negative in the nursing home. The effects of stigma
on human development and disparity in health outcomes were well documented in the
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literature (Boyd, 2018). Stigma can cause social distancing between individuals and their
environment, resulting in less engagement and satisfaction (Inan, Gunusen, Duman, &
Ertem, 2019).
Education is said to be an effective method to counteract stigma (Inan et al.,
2019). Widespread anti-stigma programs designed to increase awareness of how stigma
affects the quality of mental health care began to be widely implemented in 2005 (Inan et
al., 2019). Stigma and mental illness have been addressed in most PMH curriculum and
textbooks today including the text used by the students in the study (Boyd, 2018). In
contrast, a gap in current literature is related to how nurse educators can address stigma
and ageism in elder care.
Other contextual factors. Other sources of disengagement in LTC might have
occurred given that 47% of the students at the nursing home had prior work experience as
CNAs. Many of these students verbalized role confusion and uncertainty that they were
being prepared for a nursing role. Students who had acute care clinical at the VA and
mental health in an LTC for veterans wanted more variety in clinical experiences.
Time factors. “Wanting more” was a theme shared across cases. Qualitative
interview data showed students thought only four weeks (32 hours) of MH clinical in this
five-semester nursing program was not enough for them to learn entry level PMH
competencies as well as they wanted to or as current healthcare demographics required.
Students agreed mental health is important to overall good health, mental illness is
prevalent, and more time for classroom mental health theory, clinical education, and
simulation should be included in the nursing curriculum.
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Research Question Two
Does mental health clinical education in a nursing home or on inpatient mental
health unit have a significant effect on nursing students’ attainment of PMH
nursing competency and interest in a future career in mental health or
gerontological nursing?
Results of the study suggested baccalaureate nursing students could learn PMH
competencies in nursing homes as well as they could on an inpatient mental health unit.
Student scores on the BHCC and qualitative data certainly indicated they could. Across
cases, each of the eight groups made gains on BHCC scores post clinical. Scores ranged
from a minimum mean gain of 13 points to a maximum mean gain of 36 points in four
weeks.
These findings were not surprising given findings of previous studies that found
nursing homes were warm and welcoming CLEs that had a slower pace for novice
students where they could practice assessment skills, therapeutic communication, and
encounter important psychosocial issues such as grief, loss and transition, and end of life
care (Chen et al., 2007; Huls et al., 2015; Lea, 2014; Mezey et al., 2009). A variety of
patients and medical conditions facilitated learning (Brynildsen et al., 2014). Student
interviews confirmed these findings and highlighted many similarities between the two
CLEs that made them ideal places to develop PMH competencies. Prominent features
evident in both CLEs included access to collaboration with the interprofessional health
care team, therapeutic milieus, and staff role modeling of communication and advocacy
skills to address sociopolitical and ethical dilemmas when working with vulnerable
populations (Huls et al., 2015; Mezey et al., 2009).
Salamonson et al. (2015) found English language learners and students with prior
work experience in nursing homes were less satisfied with their clinical learning in
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nursing homes. In contrast, this study found students who reported English was not their
first language had a statistically significant difference in interest for a future career in
geriatric nursing pre and post clinical and higher levels of engagement. Linear regression
showed students with prior work experience and prior interests in mental health or
geriatric nursing were more engaged.
Qualitative findings regarding prior student work experience as a CNA were
inconclusive but appeared to be a point of dissatisfaction for students attending MH
clinical in a nursing home, which was possibly related to role confusion. Students with
prior CNA experience seemed to either have difficulty carrying out nursing assessments
and reverted to a CNA role or else they balked at having to do tasks associated with a
CNA role.
Research Question Three
What is the student nurse experience of attending PMH clinical education in
nursing homes versus inpatient mental health units?
Evidence showed nursing students had negative attitudes toward clinical
placement in nursing homes, viewed staff working in LTC as inferior, and assumed they
would learn less in nursing homes than in acute care hospitals (Annear et al., 2014;
Banning et al., 2006). These findings were confirmed in this study.
Reflecting on the qualitative themes emerging from the data, this researcher could
“see” the emergent themes were symbolic of the culture and values of each setting. For
example, in inpatient mental health, students felt constrained and restricted due to all of
the safety considerations and rules designed to keep a mental health unit safe. Yet, they
were “pleasantly and unexpectedly” surprised to find high levels of support, comfort, and
connection in a place for “crazy” people.
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The nursing home felt “like home” and was a place where students learned “to
feel like a nurse.” On the shallow side, there was a belief that this place and the people
who lived and worked there were “less than.” This myth was perpetuated at every level
of the system. At the micro system level, it occurred when student nurses who were
assigned to clinical in inpatient mental health told students assigned to a nursing home
“that place sucks. My experience is better. I am going to learn more than you.” At the
meso system level, it occurred when classroom teachers referred to LTC clinical as an
experience to be “gotten through and over with.” At the eco system level, it occurred
when healthcare workers in LTC were not paid a fair and equal wage. Fortunately, the
macro system level included some nursing students who came from cultures where elders
were valued. Those might have been the students who said “I like this place! I feel at
home here.” These embedded messages were the ones students appeared to respond
affectively to as they went to MH clinical in an inpatient MH hospital or in an LTC. The
message of being “less than” or “feeling robbed” could help nurse educators understand
why students going to clinical in LTCs often had such strong, negative reactions that
appeared to shut down their openness to learning before they even stepped onto the unit.
Research Question 4
To what extent do the similarities and differences between the groups identified
by the quantitative data support or contradict the qualitative data?
Merging the quantitative and qualitative data allowed the researcher to identify
sources of student dissatisfaction between settings that were not explained by the
quantitative data alone. Similar results conveyed by quantitative and qualitative results
showing that students could develop equivalent levels of PMH competencies across
settings strengthened the validity of the study findings.
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Recommendations for Educators
Based on student feedback and previous study results, students learned different
things in an inpatient MH unit than in a community setting such as a nursing home or
community health agency. In inpatient MH, they saw acute mental health symptoms and
had psychiatric nurse role models to shadow and learn from. In a nursing home, students
saw how people appeared when symptoms a\were “managed” and how assessments and
interventions to manage chronic symptoms varied from when people were acutely ill.
Across settings, study results highlighted the essential and important role of the clinical
nurse instructor. For a mental health clinical in a nursing home, the clinical instructor
must be an experienced PMH nurse. Likewise, nursing leaders at the nursing home site
must agree to the PMH focus and ensure appropriate residents with mental health
conditions are selected with whom students could interact.
Across cases, students interviewed said they wanted more mental health clinical
experience and would like mental health experiences in both acute and community
mental health settings. Whenever possible, student opportunities to attend clinical at
inpatient mental health and a nursing home would help them have a more realistic
understanding and view of the continuum of mental illnesses. In communities where
inpatient MH units are unavailable for the student mental health clinical, students could
learn well in a nursing home. They were likely to have a more satisfying experience with
appropriate planning by the nurse educator.
The PPCT model could be used as a planning guide. By identifying the people,
processes (ideas, tasks, and meaningful learning opportunities), and time-related factors
in the CLE, the nurse educator could assess resources and barriers to learning. Assessing
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“Context” corresponds with bioecological systems from micro to macro level spheres of
influence across systems (Bronfenbrenner & Morris, 2006). Thinking about the effects of
each level on the immediate CLE could enable nurse educators to systematically and
comprehensively analyze the CLE and identify possible explanations and solutions when
challenges occur.
Both inpatient MH units and nursing homes provide meaningful learning
environments to cultivate student attraction for a future nursing career working with
vulnerable populations. This is especially true for those students who enter clinical with
an existing interest or curiosity to explore work with the elderly or mentally ill. An
opportunity to practice appropriately leveled tasks over time is important for competency
development. There are many meaningful learning activities to engage in for students
attending mental health clinical. For example, sitting and listening is an important part of
improving therapeutic communication. However, students interviewed indicated they
wanted to “do more.” The nurse educator’s job includes facilitating development and
appreciation for all essential PMH skills—those that are more passive as well as active.
Here, the BHCC tool could be used by the nurse educator and students to monitor
progress in achieving PMH competencies over time (Rutledge et al., 2012). Students
consistently indicated psychotropic medication management and de-escalation skills were
areas of PMH competency that were harder to achieve. The nurse educator must plan
creatively for how these competencies could be met on units that would not allow
students to administer psychotropic medications or have interaction with agitated
patients.
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Many resources are available to assist the nurse educator to implement PMH
clinical education. For inpatient mental health clinical, the APNA (2016) provides an
online toolkit to help develop entry level PMH essentials for undergraduate nurses. The
toolkit has learning objectives and activities for classroom and clinical education.
Hartford Institute for Geriatric Nursing (2020) contains assessment tools with instruction
sheets and short videos students watched to learn how to conduct mental health
assessments with elders. Students benefited from conducting a mini-cognition
assessment or using the Geriatric Depression Scale (Yesavage et al., 1983) to interview
residents in a nursing home (see Appendix H). Students who used these tools to guide
their practice began to understand the abstract and complex concepts of cognition, mood,
and affect more clearly. The residents seemed to enjoy the experiences as well!
Suggestions for Additional Research
Clinical Education in Non-Traditional
Settings
More research is needed to build an evidence base for best practices in teaching,
designing, and evaluating student learning outcomes for mental health clinical education
in non-traditional settings such as an LTC, community public health agencies, prisons,
schools, primary care clinics, and homeless shelters. Nurse educators also need more
evidence to support how much curricular time and simulation/clinical education practice
students need to attain entry level PMH competency (Bowling et al., 2018). Strides have
been made to counteract stigma in mental health nursing but more research and
instructional strategies are needed to target stigma and ageism in elder care.
Personal characteristics. Study results demonstrated the need for more research
into how personal characteristics and prior experiences impacted student competency
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development during clinical education. Identification of personal characteristics of
successful PMH and geriatric nurses might assist nurse educators in recruiting and
mentoring students with these characteristics and interest in these specialties early in their
nursing education program.
Engagement, satisfaction, competency development, and learning. More
research is needed to explore the concept of student engagement as it relates to
satisfaction or dissatisfaction in clinical education and PMH nursing competency
development. Wang et al. (2018) found student satisfaction is an outcome of
engagement. Findings from this study did not show significant relationships between
student satisfaction and engagement or between engagement and competency
development. This left several questions unanswered such as whether positive learning
and growth occurred when students were dissatisfied during clinical learning. Also, it
was unknown if competency development (which included knowledge, attitudes, skills,
and mobilization of resources) required a different pedagogical approach to teaching and
learning in the clinical learning environment.
Limitations of the Study
The study findings were limited by a small sample for quantitative data collection
(N = 37). The study sample was also quite homogenous being composed of mostly
young (21 to 26 years old) female nursing students in one baccalaureate program at one
Midwestern university. Participants’ self-evaluation of their PMH nursing competencies
and engagement, the CLE, and prior relationships with the researcher might have biased
their perceptions or caused them to inaccurately report responses. The researcher’s roles
108
as a mental health clinical instructor and classroom teacher introduced strengths of being
immersed in the naturalistic study settings as well as the potential for bias.
Students were interviewed after they completed clinical and received their grades.
Participants could choose whether to be interviewed by the researcher or the research
assistant. The research assistant interviewed five students and the researcher interviewed
six students. Students interviewed by the researcher could have reported more positive
responses while students interviewed by the research assistant might have
overemphasized and complained about negative aspects because she was also a nursing
student, although in a graduate program. Limitations of the study were lessened by the
strengths of mixed methods to identify, analyze, and interpret contradictions between the
two data sets. Merging the quantitative and qualitative data allowed the researcher to
identify sources of student engagement between settings that were not explained by
quantitative data alone.
Conclusion
The findings from this mixed methods study guided by Bronfenbrenner and
Morris’ (2006) PPCT model suggested baccalaureate nursing students could learn PMH
competencies in nursing homes as well as they could on inpatient mental health units.
However, students attending MH clinical in an LTC were less satisfied with their clinical
learning experiences. The study identified possible sources of dissatisfaction as stigma,
peer influences, limited time, and personal characteristics of students as major factors.
Recommendations for nurse educators included attending to students’ desire for more
opportunities to attend MH clinical and more classroom theory related to mental health.
Students were not opposed to MH clinical in a nursing home but also wanted to observe
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“acute” mental health symptoms. Whenever possible, the opportunity to attend MH
clinical in both settings could promote more favorable attitudes toward and interest in a
future career in mental health and/or geriatric nursing. Nurse educators could use the
PPCT model to help design new models of MH clinical education across acute mental
health hospital and community settings to provide students with a more realistic
understanding of mental illness, the effects of stigma, and how to provide continuity of
care.
110
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APPENDIX A
INSTITUTIONAL REVIEW BOARD APPROVAL
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APPENDIX B
CONSENT FORM
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CONSENT FORM FOR HUMAN PARTICIPANTS IN RESEARCH
UNIVERSITY OF NORTHERN COLORADO
Project Title: Comparing student nurse experiences with developing psychiatric mental health
nursing competencies in hospital and nursing home settings: A mixed methods study.
Researcher: Maria Tice, MSN, RN, CNE, UNC Doctoral Student, School of Nursing; Asst
Professor of Nursing, St. Catherine University, St. Paul, MN
Phone Number: 651-270-8183 e-mail: [email protected]
Research Advisor: Kathryn Records, PhD, RN, FAAN, School of Nursing
email: [email protected]
I am a faculty member teaching mental health in the College for Women where you are attending
school for your baccalaureate degree in nursing. This project is part of the requirements of my
doctoral program at the University of Northern Colorado. This document will provide you with
information about the study so that you can decide whether to participate in it.
With the help of a graduate student, I am studying junior and senior level nursing students in the
College for Women to explore how they perceive they are able to learn mental health nursing
competencies in nursing homes and inpatient mental health units during their assigned clinical
education experiences. To complete this study, I am asking for your permission to participate in
two different study activities. You can agree to participate in one or both of these, or you can
decline to participate in either one. The two activities I am asking for your participation are to:
1. Agree to let me use the statistical results from the Behavioral Health Care Competency
(BHCC) and Clinical Learning Environment Inventory (CLEI) surveys you completed as
part of your clinical experiences in Fall 2018 or 2019, or that you will complete by the
end of Spring semester 2020;
2. Volunteer for an interview conducted by me or by my graduate research assistant (who
does not teach in the College for Women).
a. You can choose who you prefer to have interview you;
b. The interview will ask you to describe your perceptions about learning mental
health nursing competencies during your mental health clinical experience.
Each of these activities is detailed, below. Please read each of the statements and initial each
activity/section for which you agree to participate. Then sign your name and date the bottom of
the form.
1. I agree to allow the researcher, Ms. Tice, to include the (1) Behavioral Health Care
Competency questionnaire and the 2) Clinical Learning Environment Inventory that I
completed as part of my Interventions class during the Fall 2018, Fall or Spring 2019, or
Spring 2020 semesters in the study. I understand that these questionnaires will not be
accessed until after I have completed my mental health clinical experience and received my
mental health clinical grade. I will allow the demographic questions I complete today to be
132
used in the study. I understand that these surveys are not used to grade me; they are used to
evaluate the mental health clinical education program.
The forms will have my name removed by the research assistant and she will assign a study
number to these forms so that all my information will remain confidential and will be
reported as group data with no names associated with it. Both the research assistant and
researcher will enter the data into a computer program for analysis and the accuracy will be
checked by the researcher.
The de-identified and numbered surveys will be kept in a locked file cabinet in the
researcher’s office in a separate file from the signed consent form. The electronic data with
the survey information will be kept in a password protected electronic folder on a secure site
accessible to the researcher and research assistant only. The surveys and electronic data will
be kept for three years, then destroyed.
________________#1 Initial here
2. I agree to participate in an individual interview with the graduate research assistant or Ms.
Tice, to be conducted in Spring semester 2020 at a time that is convenient for me. The
research assistant, Lauren Kizlik, will contact me to arrange the interview. I can choose
whether I prefer to meet with Ms. Maria Tice or Lauren Kizlik, who is a graduate nursing
student at St. Catherine University. She has been trained by Ms. Tice to conduct an
interview for this study. Lauren has an undergraduate degree in Exercise Science. She has
completed her CITI human subjects’ protection training so that she understands how to
conduct research ethically and she has prior experience in conducting research with
professors at Mankato State University.
I understand that Ms. Tice will purposefully select a diverse group of students to interview
after reviewing the BHCC and CLE results. Interviews will continue until saturation is
reached. This means that I might not be contacted for an interview due to time limitations, as
individual interviews of a potential pool of 151 students in a time frame of 3 months is not
possible. The interview will be conducted in a private room in the nursing department on
campus and is estimated to last no more than one hour. The interviewer will ask open-ended
questions about my mental health clinical experience. I can share any information that I am
comfortable sharing and can decline to answer any questions. I can leave the interview at
any time or change my mind and decide not to participate without loss of any of the benefits
I am entitled to as a student.
I agree to allow my comments to be included in the study. Any specific information that
could allow others to guess my identity will be removed. If necessary, I agree to meet with
Ms. Tice to review the final research report to ensure that any comments I have made are
accurate as written. I understand that any the interview will be audio-recorded so that the
interview can be transcribed word for word. The audio- recordings will be stored in a secure
password-protected electronic folder, kept for 3 years, then destroyed.
_________________ #2 Initial here
3. There are no anticipated risks to me outside of what naturally occurs in a classroom. If I
become upset for any reason when discussing my clinical experiences during the interview,
133
Ms. Tice or Lauren Kizlik will provide me with resources to address my concerns, such as
connecting me with the counseling department on campus or with the director of the BSN
program in the College for Women.
If I participate in the study, either by allowing my statistical survey data to be included or by
agreeing to be interviewed, I will have my name entered into a random drawing for one of ten
gift cards valued at $10 each. There is no other direct benefit to participating in the study
beyond a potential feeling of satisfaction that I am providing feedback to the program. My
participation and the completion of this study may have a benefit to the nursing program and
the profession of nursing if important information about how to improve mental health
clinical education in nursing is gained. My decision to participate or not participate will not
affect my grades in my nursing classes in any way.
Participation is voluntary. You may decide not to participate in this study and if you begin
participation you may still decide to stop and withdraw at any time. Your decision will be
respected and will not result in loss of benefits to which you are otherwise entitled. A copy of this
form will be emailed to you if you request it. If you have any concerns about your selection or
treatment as a research participant, please contact the Office of Research, Kepner Hall, University
of Northern Colorado Greeley, CO 80639; 970-351-1910.
Having read the above and having had an opportunity to ask any questions, please initial
any or both of the two sections that you would like participate in for this research study and
then sign and date the bottom of the form.
______________________________________ ___________________
#3 Sign here Date _______________________________________________
Print name
134
APPENDIX C
BEHAVIORAL HEALTH CARE COMPETENCY
(WITH INDIVIDUAL ITEM MEAN SCORES)
1
Original BHCC (9 items) (Hospital nurses, N =834)
Rutledge, Wickman, Cacciata, Winokur, Loucks, & Drake, 2013
Modified MHNCC (10 items) (BSN student nurses, N = 36)
Tice, 2018
Subscale Assessment Assessment
Item
1 -C
I can assess patients for potential psychiatric problems. 3.55/5 I can assess pts for potential mental health conditions using a mental
status exam. 3.94/5
2 - NC I can identify signs and symptoms of common psychiatric conditions
(e.g. depression, schizophrenia, bipolar disorder). 3.68
I can identify signs and symptoms of common psychiatric conditions
(e.g. depression, schizophrenia, bipolar disorder). 3.97
3- C I can identify common neuroleptic, tranquilizers, and anti-depressant
medications used with psychiatric patients. 3.54
I can identify common and serious side effects of psychiatric
medications. 3.53
4- NC I am able to assess patients for risk of suicide (suicidality). 3.60 I am able to assess patients for risk of suicide (suicidality). 4.36
5- NC I recognize behaviors that indicate a patient may have alcohol or drug
abuse problems. 3.90
I recognize behaviors that indicate a patient may have alcohol or drug
abuse problems. 4.11
6 -NC I can recognize signs and symptoms of alcohol withdrawal. 3.90 I can recognize signs and symptoms of alcohol withdrawal. 4.14
7-NC I can recognize signs and symptoms of drug withdrawal. 3.76 I can recognize signs and symptoms of drug withdrawal. 3.89
8- NC I can distinguish between dementia and delirium. 3.23 I can distinguish between dementia and delirium. 3.72
9-NC I can recognize the warning signs in patients whose behavior may
escalate to aggression or dangerous behaviors. 3.61
I can recognize the warning signs in patients whose behavior may
escalate to aggression or dangerous behaviors. 3.81
I know appropriate psychiatric drugs to request physicians to order for
increasingly anxious or agitated behaviors. REWORD TO
I can recognize when to administer PRN medication to manage
increasing anxiety or agitation in patients that are not responding to
non-pharmacologic interventions.
Cronbach’s alpha 0.91 0.741 with addition of Item 10. Cronbach’s alpha of 0.724 when this
item is excluded from this subscale.
Subscale Practice/intervention Competency (8 items) Practice/intervention Competency (8 items)
NC I can initiate appropriate nursing interventions for common psychiatric
conditions such as depression, bipolar disorder, and psychosis. 3.24
I can initiate appropriate nursing interventions for common psychiatric
conditions such as depression, bipolar disorder, and psychosis. 3.53
C I can effectively interact with patients who have mental health
problems. 3.27
I can effectively interact with patients who have mental illness. 4.03
NC I am able to maintain a safe environment for patients on my unit who
have a psychiatric condition. 3.48
I am able to maintain a safe environment for patients on my unit who
have a psychiatric condition. 4.08
C I can effectively manage conflicts caused by patients who have mental
problems. 3.14
I can effectively manage conflicts caused by patients who have mental
illness.3.25
135
2
KEY: C=Change in item wording or organization, NC = No change from original.
Numbers indicate mean individual item scores on each item for the original population of RNs in practice and student nurses in a pilot study (Rutledge, et al., 2012; Tice, 2018)
NC I can effectively intervene with a patient having hallucinations. 3.04 I can effectively intervene with a patient having hallucinations. 3.03
NC I am able to use de-escalation techniques and crisis communication to
avert aggressive behaviors.3.11
I am able to use de-escalation techniques and crisis communication to
avert aggressive behaviors. 3.28
NC I plan for more time to take of patients with psychiatric issues
compared to my other patients. 3.35
I plan for more time to take of patients with psychiatric issues
compared to my other patients. 3.72
NC I am able to maintain a therapeutic relationship with most patients on
my unit who have psychiatric issues.
I am able to maintain a therapeutic relationship with most patients on
my unit who have psychiatric issues.
Cronbach’s alpha 0.90 0.843
Subscale Recommendation of Psychotropic Medication (2 items) Omitted (0 items)
I am confident that I can recommend use of psychotropic drugs to
physicians for appropriate patients.
2.65
I know appropriate psychiatric drugs to request physicians to order for
increasingly anxious or agitated behaviors. (Moved to Assessment
subscale).2.97
I recommend drugs to physicians for psychiatric patients.
2.56
Cronbach’s alpha 0.78
Subscale Resource Adequacy Resource Adequacy
NC I know when to ask for outside help (e.g. physician, psychiatric nurse,
other) for a patient with psychiatric issues or dangerous behaviors.
3.88
I know when to ask for outside help (e.g. physician, psychiatric nurse,
other) for a patient with psychiatric issues or dangerous behaviors.
3.97
NC I call for outside resources (e.g. physician, psychiatric nurse, other)
when I recognize a patient's behaviors are escalating beyond my
capabilities. 3.96
I call for outside resources (e.g. physician, psychiatric nurse, other)
when I recognize a patient's behaviors are escalating beyond my
capabilities.4.22
NC I am confident that help is available to me when I need assistance with
patients who have co-morbid behavioral or psychiatric issues.
3.59
I am confident that help is available to me when I need assistance with
patients who have co-morbid behavioral or psychiatric issues.
4.08
NC Agency resources are available to me when I need assistance with
behavioral health, or psychiatric issues, or substance abuse issues.
3.56
Agency resources are available to me when I need assistance with
behavioral health, or psychiatric issues, or substance abuse issues.
3.92
Cronbach’s alpha 0.78 0.91
Note: Subscale scores are on a scale of 1 = strongly disagree to 5= strongly agree. A score of three = uncertain.
136
136
137
APPENDIX D
ADAPTED CLINICAL LEARNING ENVIRONMENT
INVENTORY-ACTUAL
138 The purpose of this questionnaire is to find out your opinions about this clinical placement. This form of
the questionnaire assesses your opinion about what the clinical placement is actually like. Indicate your
opinions about each questionnaire statement by circling
SA if you STRONGLY AGREE D if you DISAGREE
A if you AGREE SD if you STRONGLY DISAGREE
That it describes what the clinical placement is actually like
1. The instructor/clinician considers student feelings. SA A D SD
2. The instructor/clinician talks rather than listens to the students.
3. Students look forward to coming to this clinical placement.
4. Students know exactly what has to be done in the clinical.
5. New ideas are seldom tried out in this clinical.
6. All staff at this agency are expected to do the same work in the same way.
7. The instructor/facilitator talks directly with students
8. Students put effort into what they do in this clinical.
9. Students are dissatisfied with what is done at clinical.
10. Getting a certain amount of work done is important in this clinical.
11. New and different ways of teaching are seldom used in this clinical.
12. Students are generally allowed to work at their own pace.
13. The instructor/clinicians go out of their way to help the students.
14. Students “watch the clock” in this clinical.
15. After clinical, students feel a sense of satisfaction.
16. The instructor/clinician often gets sidetracked instead of sticking to the point.
17. The facilitator thinks up fun activities for the students.
18. Students have a say in how the shift is spent.
19. The instructor/clinician helps students who are having trouble with the work
20. Students in this clinical group pay attention to what others are saying.
21. This clinical placement is a waste of time.
22. This is a disorganized clinical placement.
23. Teaching approaches at this clinical are characterized by innovation and variety.
24. Students are allowed to negotiate their work load in clinical,
25. The facilitator seldom goes around during clinical to talk to the students,
26. Students are seldom involved with the process of handing important information
over to the staff before they leave.
27. This clinical is boring.
28. Clinical assignments are clear so students know what to do.
29. The same facilitators work with the students for most of this clinical.
30. Teaching approaches allow students to work at their own pace.
31. The facilitators are not interested in students’ problems.
32. There are opportunities for students to express opinions at this clinical.
33. Students enjoy coming to this clinical.
34. Clinical instructors are punctual.
35. The facilitator would often think of interesting activities.
36. There are few opportunities for students to pursue his/her particular interest in this
clinical.
37. The facilitator is unfriendly and inconsiderate towards students.
38. The facilitator dominates debriefing sessions.
39. This clinical placement is interesting.
40. Workload allocation in the clinical experience is carefully planned.
41. Students do the same types of tasks in every clinical.
42. The instructor/clinician decides the students’ activities during clinical.
43. During this clinical I participated actively in all the learning activities.
139
44. I feel excited and curious to learn more while at this clinical.
45. During this clinical, I often think about, reflect on, or ask questions about what I am
experiencing.
46. Rather than seeking out learning activities, I wait for the clinical instructor or staff
to guide me (reverse score).
140
APPENDIX E
DEMOGRAPHIC FORM
141
COMPLETE THIS FORM ONLY IF YOU AGREE TO PARTICIPATE IN
AT LEAST ONE PART OF THE STUDY.
Student Demographic Form
1. Name:_________________________________________________________
2. Where did you attend mental health clinical?
Regions ____ MN Veterans Home ____
3. What is your age range? (Please mark appropriate range with an X)
a. 20-25 years ____
b. 26-30 years ____
c. 31-39 ____
d. 40 or over ____
4. Is English your first language? Please mark with an X.
YES _____ NO ______
If not, what is your first language?
______________________________________.
5. Do you have any previous work experience in healthcare? E.g. nursing
assistant, other?
YES _____ NO ______If yes, what did you do?
___________________________________________________________.
For how long? _____________________________________________________
142
APPENDIX F
SEMI-STRUCTURED INTERVIEW PROTOCOL
143
Semi-structured Interview Protocol*
1. Tell me about your mental health clinical experience. (Experience)
2. Talk about the people in clinical who were most helpful in your clinical learning.
a. How did they help you?
b. What did you learn from them? (Interactions with people).
[Try to reach saturation by gaining input about clinical staff, especially nurses serving in a preceptor role,
academic clinical instructors, certified nursing assistants, peers, patients, interdisciplinary health team
members].
3. a. What personal characteristics do you think students need to be successful in developing competency in
mental health nursing?
b. What personal characteristics of students are most likely to interfere with developing competency in
mental health nursing? (Personal characteristics of students).
[If examples are needed, attitudes such as fear or anxiety, aptitude for a subject, prior experience, maturity,
cognitive and emotional intelligence, would be some examples].
3. a. What learning activities did you participate in during mental health clinical?
b. Which activities were most meaningful?
c. Which activities did you enjoy most? (Participation in learning activities)
d. Which activities did you enjoy least?
4. a. What did you like most about the clinical environment at _____________?
The least? Why?
b. Which factors in the environment helped your learning?
c. Which factors in the environment interfered with or prevented with your learning? (Environment)
5. What factors related to time helped or hurt your learning experience in this clinical? Please elaborate.
(Time factors- for example is 4 clinical days long enough or too long? Are you getting enough
classroom theory related to mental health?)
6. a. Overall, how would you rate your confidence in your mental health nursing competencies after
attending MH clinical at _________________ (Regions or the nursing home), with 0 being not at all
and 5 being fully confident?
b. What factors helped in learning PMH nursing?
c. What factors prevented learning PMH nursing?
c. Did you learn anything else? If so, please describe. (Attaining PMH competency)
7. With 0 being not ready at all and 5 being fully ready, How ready are you to provide care for
mentally ill patients at this point in time?
8. Is there anything else you would like to share or suggest?
144
APPENDIX G
MODIFIED BEHAVIORAL HEALTH CARE COMPETENCY
145
ASSESSMENT
I can assess patients for potential mental health conditions using a
mental status exam.
SA A U D SD
I identify signs and symptoms of common psychiatric conditions
(e.g. depression,
schizophrenia, bipolar disorders).
SA A U D SD
I can identify common and serious side effects of anti-psychotic,
anti-anxiety, mood
SA A U D SD
stabilizers and anti-depressant medications used with patients
experiencing a mental illness.
SA A U D SD
I am able to assess patients for risk of suicide (suicidality). SA A U D SD
I recognize behaviors that indicate a patient may have alcohol or
drug abuse problems.
SA A U D SD
I can recognize signs and symptoms of alcohol withdrawal. SA A U D SD
I can recognize signs and symptoms of drug withdrawal. SA A U D SD
I can distinguish between dementia and delirium. SA A U D SD
I can recognize the warning signs in patients whose behavior may
escalate to aggression or dangerous behaviors.
SA A U D SD
PRACTICE/INTERVENTION
I can initiate appropriate nursing interventions for common
psychiatric conditions such as
SA A U D SD
depression, bipolar disorder, and psychosis. SA A U D SD
I can effectively interact with patients who have mental illnesses. SA A U D SD
I am able to maintain a safe environment for patients on my unit
who have a psychiatric condition.
SA A U D SD
I can effectively manage conflicts caused by patients who are
mentally ill.
SA A U D SD
I can effectively intervene with a patient having hallucinations. SA A U D SD
I am able to use de-escalation techniques and crisis communication
to avert aggressive behaviors.
SA A U D SD
I plan for more time to take care of patients with psychiatric issues
compared with my other patients.
SA A U D SD
I am able to maintain a therapeutic relationship with most patients
on my unit who have psychiatric issues.
SA A U D SD
I know appropriate psychotropic drugs to request physicians to
order for increasingly anxious or agitated patients.
SA A U D SD
RESOURCE ADEQUACY
I know when to ask for outside help (e.g. physician, psychiatric
nurse, other) for a patient with
SA A U D SD
psychiatric issues or dangerous behaviors. SA A U D SD
I call for outside resources (e.g. physician, psychiatric nurse, other)
when I recognize a patient’s behaviors are escalating beyond my
capabilities.
SA A U D SD
I am confident that help is available to me when I need assistance
with patients who have
SA A U D SD
146
APPENDIX H
GERIATRIC AND GERO-PSYCH NURSING CURRICULUM
AND COMPETENCY RESOURCES FOR
NURSE EDUCATORS
147
Resource Description Link
The Portal of Geriatrics
Online Education
Geropsychiatric Nursing
Competency Enhancements
A comprehensive, free collection
of educational materials,
evidence-based literature,
teaching tools, and 26 virtual
patients cases that integrate
physiological, psychological and
functional changes that occur
with aging.
The Geropsychiatric Nursing
Competency
Enhancements (Beck,
Buckwalter, & Evans, 2012)
contain seven documents
geared for entry-level nurses
and APNs who care for older
adults but are not prepared as
gerontological experts. They
build on already existing
competencies for ease of
adoption.
https://www.pogoe.org/
https://www.pogoe.org/producti
d/20660
Recommended
Baccalaureate
Competencies and
Curricular Guidelines for the
Nursing Care of Older
Adults: A Supplement to The
Essentials of Baccalaureate
Education for Professional
Nursing Practice
Developed by the American
Academy of Colleges of Nursing
(AACN) anf the Hartford Institute
for Geriatric Nursing, NYU
College of Nursing, this
document contains
Gerocompetency Statements
relating to Baccalaureate
Essentials I-IX, and
competencies, content, and
teaching strategies for
curriculum development.
https://www.aacnnursing.org/P
ortals/42/AcademicNursing/Cur
riculumGuidelines/AACN-Gero-
Competencies-2010.pdf
Consult Geri A clinical website of the Hartford
Institute for Geriatric Nursing
with many interactive resources
teaching students how to assess
health of elders using evidence-
base tools. The Try It Series
provide screening tools and
videos that students enjoy using
in clinical education.
https://consultgeri.org/
